Worker’s Compensation Application
General Information
1.
Insured’s Legal Name & DBA:
2.
Facility Address:
Street:
City:
State*:
ZIP:
* Coverage In CA not available
3.
Mailing Address:
(if different from above)
Street:
City:
State:
ZIP:
4.
Additional Location(s)
(list all locations including facility name and address):
5.
Inspection Contact Name:
Phone:
-
6.
Years in Business:
7.
Federal Employer ID Number:
8.
Employers Liability Limits:
$ 100,000 each accident
$ 500,000 disease policy limit
$ 100,000 disease each employee
Higher Limits May be Available if Requested
9.
Rating Information:
Number of Employees
Full Time
Part Time
Annual Payroll $
Clerical
Facility Ops
(Attendants, Managers,
Concessions, Clean-up)
Referees
Retail Store
Other
10.
Experience modification:
(if applicable)
11.
Individuals to be Included/Excluded
Please list all Corporate Officers and Owners and indicate if they should be included or excluded:
Name
Date of Birth
Title
Owner-ship %
Duties
Include/
Exclude
Annual Payroll $
inc
exc
inc
exc
inc
exc
Others:
12.
Prior Insurance Carrier:
13.
Claims Information
(List all Claims for the Past 5 years (attach Loss Runs),
Type “none” if Applicable):
Date:
Name of a person completing form:
Title:
Company:
Email:
Phone:
-
Fax:
-
The Monument Sports Group manages your insurance needs so that you can concentrate on growing your business.
Copyright © Monument Sports Group, 2003
