All accounts must be submitted with:
1. Acord apps 125 and the Acord for the coverage you request, WC Acord 130
2. 5 years of Loss Runs
3. Previous policy information, premium & coverage
4. Who have you marketed to: Companies, Wholesale/Retail Agencies, et al?
5. A narrative of what the company does, safety programs, hiring procedures etc.
6. Reason for account movement (non-renewed, new business, etc).
In addition to the Above Submission Requirements:
Nursing or Senior Homes:
1. MOD Worksheet / NCCI Rating Form
2. 5 years of Historical Payroll
3. 5 year Loss History currently valued
4. Target Premium
5. Owner Officer Name with DOB & SSN
6. WC codes with job description per class code
7. Safety Program/Drug Testing Information
8. Supplemental application that details training, safety, security
Property:
1. SOV, (Schedule of Values) SPREADSHEET form only not Acord form
2. Details of losses over $10,000
3. Pricing Range Needed
Workers Compensation:
1. MOD Worksheet / NCCI Rating Form (If mid-term move or does not match up with Loss we will need 2-3 yrs worksheet)
2. 5 years of Historical Payroll
3. 5 year Loss History currently valued
4. Target Premium
5. Owner Officer Name with DOB & SSN
6. WC codes with job description per class code
7. Safety Program/Drug Testing Information
8. Contractors need to submit contractor Supplimental Applications
Staffing Accounts add to submission:
1. Financials
2. Payroll Premium Projections
3. Payroll History
4. MOD Worksheet / NCCI Rating Form
5. Owner Officer Name with DOB & SSN
6. Client list with addresses & WC codes with job description per class code (Client name, Fein, address, class code, payroll)
7. Copy of client service agreement
Trucking Accounts:
1. Acord's, Comm. 125, 129, 137, 163
2. 2 yrs Financials
3. IFTA Reports, 2 yrs, only if they haul interstate
4. Percent for “Goods Hauled”, i.e. 60% sand, 20% gravel, etc…or Commodity Worksheet
5. Garage Information
6. Mileage Info, miles traveled
7. MVR’s on Drivers
8. Hiring & Safety Information
9. Truckers Supplemental Application
10. Truckers Fleet Application
Mining:
1. Mining Supplemental Application
2. Coal Truck Supplemental Auto Application
3. Mining Employee Census Application
Please note that only complete submissions will be logged in as "first received." Also, if we have not received the information necessary to process this submission, we will close the account after fifteen (15) calendar days and the market will no longer be reserved.
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