Current/Previous Insurance Information |
Current/Previous Insurer* |
None |
Annual Premium |
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Policy Period* |
Effective Date Expiration Date |
Proposed Effective Date* |
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Experience Modification Factor |
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Is a Safety Program in operation at this time* |
Please describe:
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Is this Applicant doing business as any other names or entities?* |
Please describe:
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If there is more than one entity, are the financial records maintained separately?* |
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Exactly how should the policy read?* |
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Are there any additional locations that are active under this current policy?* |
Please list:
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Are there any additional companies covered under the current policy?* |
Please list:
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(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* |
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Have deductibles been applied to losses in the past? |
Please list applicable years and deductible amount:
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Has the Applicant ever carried WC under a different name or with the KY AGC/SIF as a prior member or owner?* |
Please explain:
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Has the Applicant ever had a USL&H (Longshoreman) exposure?* |
When:
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Does the Applicant own, operate or lease an aircraft?* |
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Is the Applicant related through common ownership or management to any other entity not listed on the ACORD or KY AGC/SIF applications?* |
Please explain:
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Is the Applicant seeking WC for any other entity, subsidiary or division not listed?* |
Please explain:
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Has the Applicant experienced a name change, ownership change or merger within the past five (5) years?* |
Please explain:
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Are sub-contractors, casual laborers, contract laborers or 1099 employees used?* |
If yes, what % of the total estimated payroll can be attributed to these uninsured types of laborers?
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Does the Applicant ever hire employees, subcontractors or casual laborers from a state other than KY?* |
Has, or will, the Applicant secure WC coverage for that specific state? |
Do employees travel out of state?* |
Please list the applicable states:
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Does the Applicant have WC coverage for states other than KY?* |
Please list the applicable states:
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