130 Workers Compensation Application

Applicant name*
Internet address*
Mailing address*
City*
State*
Zip*
Years in business*
SIC. If OTHER, explain.
Explain
Credit bureau name
Federal employer identification number*
NCCI identification number
Other rating bureau identification or state employer registration number
Code
Sub code
Agency customer identification
Locations:
Location 1
Location number*
Address*
City*
State*
Zip*
Location 2
Location number
Address
City
State
Zip
Location 3
Location number
Address
City
State
Zip
Policy Information:
Proposed effective date*
Proposed expiration date*
Normal anniversary rating date
Participation
Retro plan
Rating Information:
Rating Information 1
State*
Location*
Class code
Describe code
Categories, duties, classifications
Number employees full-time
Number employees part-time
Estimated annual remuneration
Rating Information 2
State
Location
Class code
Describe code
Categories, duties, classifications
Number employees full-time
Number employees part-time
Estimated annual remuneration
Rating Information 3
State
Location
Class code
Describe code
Categories, duties, classifications
Number employees full-time
Number employees part-time
Estimated annual remuneration
Individuals Included/Excluded:
Partners, officers, relatives to be included or excluded (Remuneration to be included must be part of rating information section) 1
Name*
Date of birth*
Title/Relationship*
Percent ownership*
Duties*
Included/Excluded?*
Class code*
Remuneration*
Partners, officers, relatives to be included or excluded (Remuneration to be included must be part of rating information section) 2
Name
Date of birth
Title/Relationship
Percent ownership
Duties
Included/Excluded?
Class code
Remuneration
Partners, officers, relatives to be included or excluded (Remuneration to be included must be part of rating information section) 3
Name
Date of birth
Title/Relationship
Percent ownership
Duties
Included/Excluded?
Class code
Remuneration
Partners, officers, relatives to be included or excluded (Remuneration to be included must be part of rating information section) 4
Name
Date of birth
Title/Relationship
Percent ownership
Duties
Included/Excluded?
Class code
Remuneration
Partners, officers, relatives to be included or excluded (Remuneration to be included must be part of rating information section) 5
Name
Date of birth
Title/Relationship
Percent ownership
Duties
Included/Excluded?
Class code
Remuneration
Prior Carrier Information/Loss History:
Provide information for the past 5 years and use the explanation section for loss details)
History 1
Year
Carrier
Policy number
Annual premium
MOD
Number of claims
Amount paid
Reserve
History 2
Year
Carrier
Policy number
Annual premium
MOD
Number of claims
Amount paid
Reserve
History 3
Year
Carrier
Policy number
Annual premium
MOD
Number of claims
Amount paid
Reserve
History 4
Year
Carrier
Policy number
Annual premium
MOD
Number of claims
Amount paid
Reserve
History 5
Year
Carrier
Policy number
Annual premium
MOD
Number of claims
Amount paid
Reserve
Other history
Explain losses
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*
General Information:
Explain all YES selections
Does applicant own, operate, or lease aircraft/watercraft?*
Explain
Do/Have past, present, or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? eg. landfills, wastes, fuel tanks, etc.*
Explain
Any work performed underground or above 15 feet?*
Explain
Any work performed on barges, vessels, docks, bridge over water?*
Explain
Is applicant engaged in any other type of business?*
Explain
Are sub-contractors used? If YES, give percent of work sub-contracted in explanation*
Explain
Any work sublet without certificates of insurance?*
Explain
Is a written safety program in operation?*
Explain
Any group transportation provided?*
Explain
Any employees under 16 or over 60 years of age?*
Explain
Any seasonal employees?*
Explain
Is there any volunteer or donated labor?*
Explain
Any employees with physical handicaps?*
Explain
Do employees travel out of state?*
Explain
Are athletic teams sponsored?*
Explain
Are physicals required after offers of employment are made?*
Explain
Any other insurance with this insurer?*
Explain
Any prior coverage declined/cancelled/non-renewed within last 3 years? (not applicable in MO)*
Explain
Are employee health plans provided?*
Explain
Is there a labor interchange with any other business/subsidiary?*
Explain
Do you lease employees to or from other employers?*
Explain
Do any employees predominantly work at home?*
Explain
Any tax liens or bankruptcy within the last 5 years?*
Explain
Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? If YES, explain including entity names and policy numbers*
Explain
Contact information
Inspection phone number
Inspection name
Accounting record phone number
Accounting record name
Claims information phone number
Claims information name