The following application process is for your convenience only. Anyone may complete this application and request a quotation, however this is not an offer or promise to provide insurance. This process will not create an insurance policy nor any insurance coverage. Coverage will not be effective until after confirmed in writing by the Insurance Company.

Your Name
Company
Email
Address
City
State
Zip
County
Telephone

INFORMATION ON COMPANY APPLYING FOR COVERAGE:
Contact:
Company
DBA......
Address:
City
State
Zip
Telephone
Fax
Years in business
Best time to contact me Morning  Afternoon  Evening
Type of Entity Individual
Partnership
Corporation
Limited Corp
Supchapter "s" Corporation
Federal Employer ID Number
ADDITIONAL LOCATIONS, IF ANY:
Address City State Zip
Address City State Zip
Address City State Zip
Address City State Zip
Address City State Zip

POLICY INFORMATION 		 
Proposed Effective Date Proposed Expiration Date
Normal Anniversary Rating Date  
Workers Compensation States Other States

Employers Liability:
1,000,000 Each Accident
1,000,000 Disease-Policy Limit
1,000,000 Disease-Each Employee

  

RATING INFORMATION		  

Class Categories, Duties,
Sate. Loc. Code Classifications FT PT

Estimated Annual Remuneration

Sate. Loc. Code Classifications FT PT Estimated Annual Remuneration
Sate. Loc. Code Classifications FT PT Estimated Annual Remuneration
Sate. Loc. Code Classifications FT PT Estimated Annual Remuneration
Sate. Loc. Code Classifications FT PT Estimated Annual Remuneration


PARTNERS, OFFICERS, RELATIVES to be Included or Excluded

Name Date of Birth Title/relationship

Owner-ship Duties Inc/Exc
Name Date of Birth Title/relationship Owner-ship Duties Inc/Exc
Name Date of Birth Title/relationship Owner-ship Duties Inc/Exc
Name Date of Birth Title/relationship Owner-ship Duties Inc/Exc
Name Date of Birth Title/relationship Owner-ship Duties Inc/Exc


PRIOR CARRIER INFORMATION / LOSS HISTORY

Year Carrier & Policy Number Annual Premium Mod #Claims Amount Paid Reserve

Year Carrier & Policy Number Annual Premium Mod #Claims Amount Paid Reserve
Year Carrier & Policy Number Annual Premium Mod #Claims Amount Paid Reserve
Year Carrier & Policy Number Annual Premium Mod #Claims Amount Paid Reserve
Year Carrier & Policy Number Annual Premium Mod #Claims Amount Paid Reserve

NATURE OF BUSINESS

GENERAL INFORMATION
1. Does applicant own, operate or lease aircraft/watercraft? Yes No

2. Do/have past, present or discontinued operations involve(d).
storing, treating, discharging, applying, disposing or transporting of hazardous material?
(e.g. landfills, wastes, fuel tanks, etc.)

 Yes No
3. Any work performed underground or above 15 feet? Yes No
4. Any work performed on barges, vessels, docks, bridge over water? Yes No
5. Is applicant engaged in any other type of business? Yes No
6. Are sub-contractors used? (If yes, give % of work subcontracted) Yes No
7. Any work sublet without certificates of Insurance? Yes No
8. Is a written safety program in operation? Yes No
9. Any group transportation provided? Yes No
10. Any employees under 16 or over 60 years of age? Yes No
11. Any seasonal employees? Yes No
12. Is there any volunteer or donated labor? Yes No
13. Any employees with physical handicaps? Yes No
14. Do employees travel out of state? Yes No
15. Are athletic teams sponsored? Yes No
16. Are physicals required after offers of employment are made? Yes No
17. Any other insurance with this insurer? Yes No
18. Any prior coverage declined/cancelled/non-renewed (last 3 years)? Yes No
19. Are employee health plans provided? Yes No
20. Is there a labor interchange with any other business/subsidiary? Yes No
21. Do you lease employees to or from other employers? Yes No
22. Do any employees predominantly work at home? Yes No
23. Any tax leins or bankruptcy within the last 5 years? Yes No
Inspection Contact Name Inspection Contact Phone
Accounting Records Name Accounting Records Phone
Claims Information Name Claims Information Phone