ACORD ™

WORKERS COMPENSATION APPLICATION

DATE

AGENCY
PHONE: (A/C,Ext)
FAX: (A/C, No)
E-MAIL ADDRESS
CODE:
SUBCODE:
AGENCY CUSTOMER ID:

COMPANY

APPLICANT NAME

UNDERWRITER

E-MAIL ADDRESS

MAILING ADDRESS (Including ZIP code)

YRS IN BUS	SIC	INDIVIDUAL	CORPORATION	LLC
		PARTNERSHIP	SUB "S" CORP	OTHER

CREDIT BUREAU NAME ID NUMBER:

FED.EMPLOYER ID #

NCCI ID #

OTHER RATE BUREAU ID OR STATE EMPLOYER REG #

STATUS OF SUBMISSION

BILLING/AUDIT INFORMATION

QUOTE ISSUE POLICY
BOUND (Give date and/or attach copy)
ASSIGNED RISK (Attach ACORD 133)

BILLING PLAN
AGENCY BILL
DIRECT BILL

PAYMENT PLAN
ANNUAL
SEMI-ANNUAL
QUARTERLY

OTHER
% DOWN:

AUDIT:
AT EXPIRATION
SEMI-ANNUAL
QUARTERLY
MONTHLY OTHER:

LOCATIONS

LOC#	STREET, CITY, COUNTY, STATE, ZIP CODE

POLICY INFORMATION

PART 1 - WORKERS
COMPENSATION (States)

PART 2 - EMPLOYER'S LIABILITY

$		EACH ACCIDENT
$		DISEASE-POLICY LIMIT
$		DISEASE-EACH EMPLOYEE

PART 3 - OTHER STATES INS.

DEDUCTIBLES
MEDICAL
INDEMNITY

AMOUNT%

OTHER COVERAGES
U.S.L.&H.
MANAGED CARE OPTION
VOLUNTARY COMP
FOREIGN COV

DIVIDEND PLAN/SAFETY GROUP

RATING INFORMATION STATE LOC# CLASS CODE DESCR CODE CATEGORIES, DUTIES, CLASSIFICATIONS # EMPLOYEES ESTIMATED ANNUAL REMUNERATION RATE ESTIMATED ANNUAL PREMIUM FULL TIME PART TIME STATE: FACTOR FACTORED PREMIUM FACTOR FACTORED PREMIUM SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS TOTAL $ CCPAP $ INCREASED LIMITS $ STANDARD PREMIUM $ DEDUCTIBLE $ PREMIUM DISCOUNT $ $ EXPENSE CONSTANT N/A $ EXPERIENCE/MERIT MODIFICATION $ TAXES / ASSESSMENTS N/A $ LOSS CONSTANT N/A $ $ ASSIGNED RISK SURCHARGE $ EST. ANNUAL PREMIUM N/A $ ARAP $ TOTAL ESTIMATED ANNUAL PREMIUM N/A $ $ MINIMUM PREMIUM $ SCHEDULED RATING $ DEPOSIT PREMIUM $ ADDITIONAL COMPANY INFORMATION

PRIOR CARRIER INFORMATION/LOSS HISTORY

PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS LOSS RUN ATTACHED
YEAR	CARRIER & POLICY #	ANNUAL PREMIUM	MOD	# CLAIMS	AMOUNT PAID	REMUNERATION

ACORD130 (2004/03)

© ACORD CORPORATION 1980

INDIVIDUALS INCLUDED/EXCLUDED

PARTNERS, OFFICERS, RELATIVES TO INCLUDED OR EXCLUDED. (Remuneration to be included must be part of rating information section.)
STATE	LOC#	NAME	DATE OF BIRTH	TITLE/RELATIONSHIP	OWNER SHIP %	DUTIES	INC/EXC	CLASS CODE	REMUNERATION

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS

GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS OPERATIONS AND PRODUCTS: MANUFACTURING-- RAW MATERIALS PROCESSES PRODUCT, EQUIPMENT. CONTRACTOR-- TYPE OF WORK, SUB-CONTRACTS. MERCANTILE--MERCHANDISE, CUSTOMERS, DELIVERIES. SERVICE--TYPE, LOCATION. FARM--ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS.

GENERAL INFORMATION

EXPLAIN ALL YES RESPONSES

Yes/No

EXPLAIN ALL YES RESPONSES

Yes/No

DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT?

18.

ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED (Last 3 years)? NOT APPLICABLE IN MO

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)

19.

ARE EMPLOYEE HEALTH PLANS PROVIDED?

20.

IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?

ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?

21.

DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

ANY WORK PERFORMED ON BARGES. VESSELS. DOCKS. BRIDGE OVER WATER?

22.

DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?

IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?

23.

ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS?

ARE SUB-CONTRACTORS USED? (IF YES. GIVE % OF WORK SUBCONTRACTED)

ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.?

CONTACT INFORMATION

IS A WRITTEN SAFETY PROGRAM IN OPERATION?

INSPECTION	PHONE:
	NAME:
	EMAIL:
ACCOUNTING RECORD	PHONE:
	NAME:
	EMAIL:
CLAIMS INFO	PHONE:
	NAME:
	EMAIL:

ANY GROUP TRANSPORTATION PROVIDED?

10.

ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?

11.

ANY SEASONAL EMPLOYEES?

12.

IS THERE ANY VOLUNTEER OR DONATED LABOR?

13.

ANY EMPLOYEES WITH PHYSICAL HANDICAPS?

14.

DO EMPLOYEES TRAVEL OUT OF STATE?

15.

ARE ATHLETIC TEAMS SPONSORED?

16.

ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?

17.

ANY OTHER INSURANCE WITH THIS INSURER?

APPLICABLE IN TENNESSEE: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS COM-PENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CON-CERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND JNY: SUBSTANTIAL] CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR; IN ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED)

REMARKS

APPLICANT'S SIGNATURE	DATE	PRODUCER'S SIGNATURE	NATIONAL PRODUCER NUMBER

ACORD 130 (2004/03)