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Business Entity is a(n) : *
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Individual
Corporation
LLC
Partnership
S-Corp
Other
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Name of Applicant: *
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E-Mail Address: *
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Doing Business As: *
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Location Address: *
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City: *
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State: *
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Zip: *
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5 digit
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Years in Business: *
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(not years experience)
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Federal ID / Soc. Sec. Number: *
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(99-9999999 or 999-99-9999)
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Street :*
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City :*
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State :*
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Zip : *
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Proposed Effective Date: *
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(dd/mm/yy)
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Part 1 WORKERS COMPENSATION STATE: *
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Part 2 EMPLOYERS LIABILITY: *
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Each Accident :*
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Disease-Policy Limit :*
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Disease-Each Employee :*
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State
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Categories, Duties, Classifications
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# Full Time Employees
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# Part Time Employees
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Est. Annual Payroll
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*Georgia
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*
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*
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*
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*
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Georgia
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Georgia
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Owners, Partners, Executives to be included or excluded (Payroll to be included must be part of rating information section.) - - Do not list Employees - -
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Name *
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Owner % *
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Birth date *
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Inc/Exc *
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Payroll *
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Describe Business*
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Enter Loss history, if none enter "no loss history" *
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PLEASE EXPLAIN IN THE REMARKS SECTION ANY 'YES' ANSWERED TO THE BELOW QUESTIONS.
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1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT?
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Yes
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No
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2. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATION INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc.)
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Yes
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No
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3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
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Yes
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No
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4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
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Yes
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No
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5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
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Yes
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No
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6. ARE SUB-CONTRACTORS USED? (IF YES, GIVE % OF WORK SUBCONTRACTED IN RAMARKS SECTION)
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Yes
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No
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7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE?
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Yes
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No
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8. IS A WRITTEN SAFETY PROGRAM IN OPERATION?
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Yes
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No
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9. ANY GROUP TRANSPORTATION PROVIDED?
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Yes
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No
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10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
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Yes
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No
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11. ANY SEASONAL EMPLOYEES?
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Yes
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No
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12. IS THERE ANY VOLUNTEER OR DONATED LABOR?
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Yes
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No
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13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
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Yes
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No
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14. DO EMPLOYEES TRAVEL OUT OF STATE?
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Yes
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No
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15. ARE ATHLETIC TEAMS SPONSORED?
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Yes
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No
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16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
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Yes
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No
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17. ANY OTHER INSURANCE WITH THIS INSURER?
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Yes
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No
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18. ANY PRIOR COVERAGE DECLINE/CANCELLED/NON-RENEWED (Last 3 years)? Not Applicable in MO
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Yes
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No
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19. ARE EMPLOYEE HEALTH PLANS PROVIDED?
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Yes
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No
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20. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?
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Yes
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No
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21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
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Yes
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No
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22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?
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Yes
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No
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23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS?
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Yes
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No
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24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OWNED ENTERPRISES? IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBERS(S) IN REMARKS SECTION.
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Yes
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No
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REMARKS:
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PHONE (I.E. 999-999-9999)
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NAME
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Your Phone number:
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*
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*
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SUBMISSION OF THIS APPLICATION IN NO WAY CONSTITUTES APPROVAL FOR BINDING. BINDING WILL BE CONFIRMED BY A WRITTEN RELEASE OF A BINDER NUMBER AFTER ALL REQUIREMENTS ARE RECEIVED IN OUR OFFICE. RATE IS BASED ON INFORMATION PROVIDED ON THIS APPLICATION AND IS SUBJECT TO CHANGE.
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