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Home > Business > Worker's Compensation Applicant Information
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Worker's Compensation Applicant Information


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Applicant Information
First Name *
Last Name *
E-Mail Address *
Mailing Address
Street *
City *
State / Province *
ZIP / Postal Code *
Application Type




Years in Business
Effective Date of Coverage
Employers Liability Limits $500,000/$500,000/$500,000 Indicate change if needed
Federal Tax ID #
Locations
Enter Up to 3 Locations
Address
City
State
Zip
County
Address
City
State
Zip
County
Address
City
State
Zip
County
Description of Operations






Other Type
Hours of Operations
Experience Modification Factor
Modification Factor
Please provide (via fax or email) a copy of the experience modification worksheet
Normal Anniversary Date
Rating Information
A maximum of 6 ratings are allowed
Class Code
Number of Employees
Categories, Duties, Classification
Annual Payroll
Rate
Estimated Annual Premium
Class Code
Number of Employees
Categories, Duties, Classification
Annual Payroll
Rate
Estimated Annual Premium
Class Code
Number of Employees
Categories, Duties, Classification
Annual Payroll
Rate
Estimated Annual Premium
Class Code
Number of Employees
Categories, Duties, Classification
Annual Payroll
Rate
Estimated Annual Premium
Class Code
Number of Employees
Categories, Duties, Classification
Annual Payroll
Rate
Estimated Annual Premium
Class Code
Number of Employees
Categories, Duties, Classification
Annual Payroll
Rate
Estimated Annual Premium
Ownership Information
A maximum of 4 owners are allowed
Name
Title/Relationship
Duties
Payroll
Age
Ownership %
Include/Exclude
Name
Title/Relationship
Duties
Payroll
Age
Ownership %
Include/Exclude
Name
Title/Relationship
Duties
Payroll
Age
Ownership %
Include/Exclude
Name
Title/Relationship
Duties
Payroll
Age
Ownership %
Include/Exclude
Insurance Company Loss Runs
Provide Insurance Company Loss Runs for the past 3 years and use the remarks section for loss details. Previous Insurance Company Loss Information is required prior to binding.
A maximum of 4 previous insurance items are allowed.
Policy Period From
Company
Annual Premium
# of Claims
Reserve
Policy Period To
Policy Number
Exp. Mod
Amount Paid
Total
Policy Period From
Company
Annual Premium
# of Claims
Reserve
Policy Period To
Policy Number
Exp. Mod
Amount Paid
Total
Policy Period From
Company
Annual Premium
# of Claims
Reserve
Policy Period To
Policy Number
Exp. Mod
Amount Paid
Total
Policy Period From
Company
Annual Premium
# of Claims
Reserve
Policy Period To
Policy Number
Exp. Mod
Amount Paid
Total
General Information
Please provide all the required details for “Yes” responses by using the remarks area below. Use a separate sheet if necessary.
Does applicant own, operate or lease aircraft/watercraft?

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.)

Any work performed underground or above 15 feet?

Any work performed on barges, vessels, docks, bridge over water?

Is applicant engaged in any other type of business?

Are sub-contractors used?

Any work sublet without certificates of insurance?

Is a formal safety program in operation?

Any group transportation provided?

Any employees under 16 or over 60 years of age?

Any part-time or seasonal employees?

Is there any volunteer or donated labor?

Any employees with physical handicaps?

Do employees travel out of state?

Are athletic teams sponsored?

Are physicals required after offers of employment?

Any other insurance with this insurer?

Any prior coverage declined/canceled/non-renewed (last 3 years)? Not Applicable In Missouri

Are employee health plans provided?

Is there a labor interchange with any other business or subsidiary?

Do you lease employees to or from other employers?

Do any employees predominately work at home?

Workers' Compensation Applicant Information
Additional information or remarks
Contact Name
Phone Number
Fax Number
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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