Membership Application

Note: All fields marked with an asterisk * are required.

General Information
Person Completing Application*
Name of Business*
FEIN
Owner/Officer(s)* Name Title
Contact Name*
Contact Phone & Fax* Phone Fax
Contact E-mail Address
Physical Address*
City State Zip
Is Mailing Address same as Physical*
Mailing Address
City State Zip
Payroll & Premium Contact*
Claims Contact*
Safety Contact*
Type of Entity*
Years in Business*
Date Business Started*
Years of Operation-Related Experience*
Proposed Trade Association* Local # 
Description of Operations*
Insurance Agency* None
Insurance Agent
Agent Phone & Fax* Phone Fax
Agent E-mail Address*
Agent Address*
Agency Association

Note: All fields marked with an asterisk * are required.

Current/Previous Insurance Information
Current/Previous Insurer* None
Annual Premium
Policy Period* Effective Date Expiration Date
Proposed Effective Date*
Experience Modification Factor
Is a Safety Program in operation at this time*
Is this Applicant doing business as any other names or entities?*
If there is more than one entity, are the financial records maintained separately?*
Exactly how should the policy read?*
Are there any additional locations that are active under this current policy?*
Are there any additional companies covered under the current policy?*
(If business is a Sole Proprietorship/Partnership/LLC) Do the Owner/Partner(s) wish to be Included/Excluded? If Included, then an Election notice with original signatures is needed.
(If business is a Corporation) Do the Owner/Partner(s) wish to be Included/Excluded? If Excluded, then an Original or Filed Form-4 Rejection Notice is needed.
Estimated Number of Employees*
Have deductibles been applied to losses in the past?
Has the Applicant ever carried WC under a different name or with the KY AGC/SIF as a prior member or owner?*
Has the Applicant ever had a USL&H (Longshoreman) exposure?*
Does the Applicant own, operate or lease an aircraft?*
Is the Applicant related through common ownership or management to any other entity not listed on the ACORD or KY AGC/SIF applications?*
Is the Applicant seeking WC for any other entity, subsidiary or division not listed?*
Has the Applicant experienced a name change, ownership change or merger within the past five (5) years?*
Are sub-contractors, casual laborers, contract laborers or 1099 employees used?*
Does the Applicant ever hire employees, subcontractors or casual laborers from a state other than KY?*
Do employees travel out of state?*
Does the Applicant have WC coverage for states other than KY?*

Note: All fields marked with an asterisk * are required.

Payroll & Class Code Information
Class Code or Job Description* #FT Employees #PT Employees Estimated Payroll per Class Code
Optional - Upload Supporting Documents
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