Workers Compensation Form printable pdf download

WORKERS COMPENSATION

PREMIUM INDICATION ONLY

CLIENT NAME: _________________________________________________ TEL #: ______________________________________________

ADDRESS:

_________________________________________________ FID# _______________ YEARS EST’D _________________

CITY, ST, ZIP:

_________________________________________________ CORP / IND / PTRSHP / OTHER: _____________________

DESCRIPTION OF OPERATIONS: ______________________________________________________________________________________

LOSS HISTORY: POOR / GOOD / EXCELLENT --

* Have Current Loss Runs Been Ordered? YES / NO

OWNERS

NAME: _______________________________ TITLE: _________________ CLASS: ______________ P-ROLL: $_____________________

NAME: _______________________________ TITLE: _________________ CLASS: _______________ P-ROLL: $_____________________

RATING INFORMATION

LIMITS: 100/500/100 - 500/500/500 - 1M/1M/1M -- DEDUCTIBLE: $0 / $500 / $1000 / $2000 / $2500 / $5000

ANNIVERSARY RATE DATE: ___________ CURRENT EXP MOD/MERIT RATING : ___________ ARAP: _________

CLASS: _________________________ PAYROLL: $ ________________________________

CLASS: _________ 7380 ___________ PAYROLL: $ ________________________________

CLASS: _________ 8742 ___________ PAYROLL: $ ________________________________

CLASS: _________ 8810 ___________ PAYROLL: $ ________________________________

PREFERRED DEVIATION: ___________________________________%

Are subcontractors used? If so, percentage of subbed work? _______________________________________________________________

If there is a written formal safety program in operation? __________________________________________________________________

Are there part-time or seasonal employee’s used? ________________________________________________________________________

Are there any leased employees? _______________________________________________________________________________________

COMPANY: ____________________________ EST’D PREMIUM: $ _________________ DEVIATION: ________% DATE: ___________

PLMT NOTES: ___________________________________________________________________________________________

AXiA Insurance Services, Inc.

73 Marketplace, P.O. Box 15648

Tel: 413-205-AXIA (2942)

Springfield, MA 01115

Fax: 413-886-0190

Workers Compensation Form