Required Forms

Please download and complete the attached forms (3 forms).

 

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1. Large Deductible Workers' Compensation Application
    

2. Workers' Compensation Application
    

3. Commercial Insurance Application

 

 

To properly prepare, we also need the following documentation:

 

1. Current Experience Modification worksheet, evidencing workers' compensation payrolls for the three (3) prior years. Evidence of workers' compensation payrolls for an additional two (2) years prior (either carriers' final audits or an older experience modification worksheet showing those payrolls).

2. Currently valued (within 90 days of the proposed policy effective date) loss runs for the current year and five (5) prior years.

3. Details of any single loss paid/reserved at an amount over 50% of the proposed deductible level.

4. Most currently available audited financial statements.

5. Information concerning the insured's use of any uninsured subcontractors.