Fillable WORKERS COMPENSATION APPLICATION

Fill Online, Printable, Fillable, Blank WORKERS COMPENSATION APPLICATION Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

WORKERS COMPENSATION APPLICATION

On average this form takes 116 minutes to complete

The WORKERS COMPENSATION APPLICATION form is 4 pages long and contains:

  • 0 signatures
  • 35 check-boxes
  • 447 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PRODUCER NAME:
CS REPRESENTATIVE
NAME:
OFFICE PHONE
(A/C, No, Ext)
AGENCY CUSTOMER ID:
CODE: SUB CODE:
ADDRESS:
E-MAIL
FAX
(A/C, No):
MOBILE
PHONE:
AGENCY NAME AND ADDRESS
OTHER
ADDRESS:
WEBSITE
JOINT VENTURE
TRUST
E-MAIL ADDRESS:
MOBILE PHONE:OFFICE PHONE:
APPLICANT NAME:
ID NUMBER:
UNDERWRITER:
COMPANY:
SIC:
FEDERAL EMPLOYER ID NUMBER NCCI RISK ID NUMBER
OTHER RATING BUREAU ID OR STATE
EMPLOYER REGISTRATION NUMBER
CREDIT
BUREAU NAME:
LLC
SUBCHAPTER "S" CORP
CORPORATION
PARTNERSHIP
SOLE PROPRIETOR
MAILING ADDRESS (including ZIP + 4 or Canadian Postal Code)
NAICS:
YRS IN BUS:
DATE (MM/DD/YYYY)
WORKERS COMPENSATION APPLICATION
PARTNERS, OFFICERS, RELATIVES ( Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.)
Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.
NAME DATE OF BIRTH
TITLE/
RELATIONSHIP
OWNER-
SHIP %
DUTIES INC/EXC CLASS CODE REMUNERATION/PAYROLL
LOC #STATE
INDIVIDUALS INCLUDED / EXCLUDED
$
TOTAL DEPOSIT PREMIUM ALL STATES
$
TOTAL MINIMUM PREMIUM ALL STATES
$
TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES
TOTAL ESTIMATED ANNUAL PREMIUM - ALL STATES
OFFICE PHONE
INFO
CLAIMS
RECORD
TYPE
ACCTNG
INSPECTION
CONTACT INFORMATION
E-MAILMOBILE PHONENAME
The ACORD name and logo are registered marks of ACORD
SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
PART 3 - OTHER
STATES INS
DISEASE-EACH EMPLOYEE
DISEASE-POLICY LIMIT
EACH ACCIDENT
$
$
$
PART 2 - EMPLOYER'S LIABILITY
PART 1 - WORKERS
COMPENSATION (States)
PROPOSED EXP DATEPROPOSED EFF DATE
POLICY INFORMATION
RETRO PLAN
PARTICIPATING
NON-PARTICIPATING
NORMAL ANNIVERSARY RATING DATE
AMOUNT / %
(N / A in WI)
(N / A in WI)
DEDUCTIBLES
MEDICAL
INDEMNITY
ADDITIONAL COMPANY INFORMATIONDIVIDEND PLAN/SAFETY GROUP
U.S.L. & H.
CARE OPTION
MANAGED
FOREIGN COV
COMP
VOLUNTARY
OTHER COVERAGES
LOCATIONS
FLOOR
HIGHEST
STREET, CITY, COUNTY, STATE, ZIP CODE
LOC #
BILLING PLAN
AGENCY BILL
DIRECT BILLASSIGNED RISK (Attach ACORD 133)
BOUND (Give date and/or attach copy)
ISSUE POLICYQUOTE
BILLING / AUDIT INFORMATIONSTATUS OF SUBMISSION
PAYMENT PLAN
ANNUAL
SEMI-ANNUAL
QUARTERLY % DOWN:
AUDIT
AT EXPIRATION
SEMI-ANNUAL
QUARTERLY
MONTHLY
ACORD 130 (2010/05) Page 1 of 4 © 1980-2010 ACORD CORPORATION. All rights reserved.
ACORD 130 (2010/05)
REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
AGENCY CUSTOMER ID:
OF SHEETSSTATE RATING SHEET #
RATING INFORMATION - STATE:
Page 2 of 4
FOR MULTIPLE STATES, ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM
STATE RATING WORKSHEET
* N / A in Wisconsin
N / A
N / A
N / A
MODIFICATION
TAXES / ASSESSMENTS *
FACTORED PREMIUM
EXPERIENCE OR MERIT
FACTOR
$ $ $
DEPOSIT PREMIUMMINIMUM PREMIUMTOTAL ESTIMATED ANNUAL PREMIUM
STANDARD PREMIUM $
$
SCHEDULE RATING *
$
CCPAP
FACTORED PREMIUM
FACTOR
STATE:
$TOTAL
$INCREASED LIMITS
DEDUCTIBLE * $
$
$
$
$ASSIGNED RISK SURCHARGE *
$ARAP *
$
$PREMIUM DISCOUNT
$EXPENSE CONSTANT
$
$
PREMIUM
DESCR
CODE
ESTIMATED
ANNUAL MANUAL
PREMIUM
ESTIMATED ANNUAL
REMUNERATION/
PAYROLL
SIC NAICSLOC # CLASS CODE CATEGORIES, DUTIES, CLASSIFICATIONS
# EMPLOYEES
RATE
FULL
TIME
PART
TIME
ACORD 130 (2010/05)
Y / N
AGENCY CUSTOMER ID:
6. ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)
7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If "YES", payroll for this work must be included in the State Rating Worksheet on Page 2)
9. ANY GROUP TRANSPORTATION PROVIDED?
8. IS A WRITTEN SAFETY PROGRAM IN OPERATION?
10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
11. ANY SEASONAL EMPLOYEES?
12. IS THERE ANY VOLUNTEER OR DONATED LABOR? (If "YES", please specify)
GENERAL INFORMATION
2.
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)
3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
EXPLAIN ALL "YES" RESPONSES
1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT?
Page 3 of 4
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.
NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS
PRIOR CARRIER INFORMATION / LOSS HISTORY
PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS
LOSS RUN ATTACHED
RESERVEAMOUNT PAID# CLAIMSMODANNUAL PREMIUMCARRIER & POLICY NUMBERYEAR
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
ACORD 130 (2010/05)
REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
APPLICABLE IN TENNESSEE AND VERMONT: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO
ANY PARTY TO A WORKERS COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE
IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE
PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES.
IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY
FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, 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 CONCERNING ANY FACT MATERIAL THERETO, MAY BE
COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
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 CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND
SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, MA, MN, NE, OH, OK, OR, VT
or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
APPLICANT'S SIGNATURE (Must be Officer, Owner or Partner) DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER
Y / N
AGENCY CUSTOMER ID:
13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
24.
ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES?
IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S).
23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS? (If "YES", please specify)
22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If "YES", # of Employees:
21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
20. DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?
GENERAL INFORMATION (continued)
Page 4 of 4
14. DO EMPLOYEES TRAVEL OUT OF STATE? (If "YES", indicate state(s) of travel and frequency)
15. ARE ATHLETIC TEAMS SPONSORED?
19. ARE EMPLOYEE HEALTH PLANS PROVIDED?
18. ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)
EXPLAIN ALL "YES" RESPONSES
16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
17. ANY OTHER INSURANCE WITH THIS INSURER?
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

WORKERS COMPENSATION APPLICATION

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 May 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document