Worker's Compensation Applicant Information

Mailing Address



Enter up to 3 locations

Description of Operations

Experience Modification Factor

Please provide (via fax or email) a copy of the experience modification worksheet

Rating Information

A maximum of 6 ratings are allowed.

Ownership Information

A maximum of 4 owners are allowed.

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.

Workers' Compensation Applicant Information

Workers' Compensation Applicant Information

NOTICE OF INSURANCE INFORMATION PRACTICES - Personal information about you, including information from a credit report may be collected from persons other than you in connection with this application for insurance and subsequent policy renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instructions on how to submit a request to us. ACORD 125 (2005/06) This application does not bind the applicant, the company, or the agent to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.