Acord 130 Acord 130 Date Completed Agency Information Agency Name: E-Mail Address Phone Number Fax Number Code Sub Code Agency Customer ID COMPANY INFORMATION Company Type of Underwriter Applicant Name E-Mail Address Mailing Address (including ZIP + 4) Years In Business SIC NAICS Code What"s the type of Company Individual Partnership Corporation Subchapters Corp LLC Other Company Other Credit Bureau Name ID Number FEIN Number NCCI Number Other rating bureau ID or state employer registration Number LOCATION Location Number of Company Adress of company( STREET, CITY, COUNTY, STATE, ZIP CODE) POLICY INFORMATION Proposed Effectiv Date Proposed Expirated Date Normal Anniversary Rating Date Retro Plan Type of policy Participating Non-Participating PART 1 Workers Compensation State PART 2- Employer Liability Each Accident ($) Disease-Policy Limit ($) Diseas-each employer ($) PART 3- Other State Ins Amount Deductible Medical Indemnity Other Deductible Other deductible Other Coverages U.S.L & H Voluntary Comp Foreign Cov Managed care option Other Other converages Dividend Plan/Safety Group Additional Company Information State Location Number Class Code Description Code Categories, Duties, Classification Number of Full Time employer Number of Part Time employer Estimated Annual Remuneration Rate Estimated Annual Premium State FACTOR FACTOR PREMIUM Factor Total Total($) Increased Limits Increased Limits($) Deductible Deductible ($) State Experience or merit modification Experience or merit modification ($) Loss constant N/A LOSS CONSTANT($) Assigned risk surcharge Assigned risk surcharge($) Arap Arap($) State Schedule Rating Schedule Rating($) CCPAP CCPAP ($) Standard Premium Standard Premium($) Premium discount Premium discount($) Expense constant N/A Expense Constant($) Taxes/Assessments N/A Taxes/Assessments($) Estimate annual premium N/A Estimated annual premium($) Rating Information Total estimated annual Premium N/A Total estimated annual Premium Minimum Premium N/A Minimum Premium Minimum Premium N/A Deposit premium Specify additional coverages /endorsements INDIVIDUALS INCLUDED/EXCLUDED PARTNERS, OFFICERS, RELATIVES TO BE INCLUDED OR EXCLUDED. (Remuneration to be included must be part of rating information section.) State Location Name Date Of Birth Title-Relationship Ownership Duties Include-Exclude Class Code Remuneration NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Give comments and description of business, operation and product : Manufacturing - raw materials,Processes , Product , Equipment .Contractor --Type of :Work, Sub-Contractor.Mercantile--Merchandise, Customers, Deliveries.Service --type, Location.Farm--Acreage,Animals,Machinery, Sub-Contracts 1.Does applicant own, operate or lease aircraft/watercraft? Yes No 2. Do/Have past, present or discontinues operations involve(d) storinf, treating, dischaging, applying, disposing, or transporting of hazardous material?(e.g. landfills, wastes, fuel tanks, etc) Yes No 3. Any work perfomed undergroup or above 15 feet? Yes No 4. Any work perfomed on barages ,Vessels, Docs, Bridge, over water? Yes No 5. Is applicant engaged in any other type of business? Yes No 6. Are sub-contractor used? (if yes , give % of work subcontractors. Yes No 7. Any work sublet without certificates of INS .? Yes No 8. Is a written safety program in operation? Yes No 9. Any group transportation provide? Yes No 10. Any employer under 16 or 60 years of age Yes No 11.Any seasonal employer ? Yes No 12.Is there any volunter or donated labor? Yes No 13. Any employer with physical handicaps? Yes No 14.Do employer travel out of state Yes No 15.Are athletic teams sponsored? Yes No 16. Are physicals required after offers of employer are made? Yes No 17. Ant other insurance with this insurer? Yes No 18. Any prior coverage declined/cancelled/non-renewed(Last 3 years)? Yes No 19. Are employer health plans provided? Yes No 20. Is there a labor interchange with any other business/subsidiary? Yes No 21. Do you lease employer to or from other employer ? Yes No 22. Do any employer predominatly work at home? Yes No 23. Any tax liens or bankruptcy within the last 5 years? Yes No 24. Any udesputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? if yes, explain including entity name(s) and policy numbers(s) Yes No CONTACT INFORMATION Inspection Phone Name E-Mail Accounting Record Phone Name E-Mail Claims information Phone Name E-Mail REMARKS (Attach additional sheets if more space is required) APPLICANT'S SIGNATURE Date Completed National Prdoducer Number
