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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

Individual
Partnership
Corporation
LLC
Other

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

Full Service
Self Service
Exterior Only
Lube & Oil
Gas
Retail Store
Open 24 Hours

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?

Yes
No

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

Any work performed underground or above 15 feet?

Yes
No

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

Yes
No

Is applicant engaged in any other type of business?

Yes
No

Are sub-contractors used?

Yes
No

Any work sublet without certificates of insurance?

Yes
No

Is a formal safety program in operation?

Yes
No

Any group transportation provided?

Yes
No

Any employees under 16 or over 60 years of age?

Yes
No

Any part-time or seasonal employees?

Yes
No

Is there any volunteer or donated labor?

Yes
No

Any employees with physical handicaps?

Yes
No

Do employees travel out of state?

Yes
No

Are athletic teams sponsored?

Yes
No

Are physicals required after offers of employment?

Yes
No

Any other insurance with this insurer?

Yes
No

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

Yes
No

Are employee health plans provided?

Yes
No

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

Yes
No

Do you lease employees to or from other employers?

Yes
No

Do any employees predominately work at home?

Yes
No

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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