Worker’s Compensation Please complete all required fieldsFirst Name *Last Name Email Address *License # *FEIN Years In Business Years Experience EXMOD WORKER’S COMP INSURANCE HISTORY3 years history required if available Current Insurance Company Effective date’s Policy # Premium 1 Year Previous Effective date’s Policy # Premium 2 Year Previous Effective date’s Policy # Premium LOSS RUNS **IF YOU DO HAVE THE LOSS RUNS PLEASE UPLOAD WITH THIS APPLICATION**Upload Loss Runs Note: Current policy info is required to get additional significant discounts. Declaration page may be needed. file formats accepted png|jpe?g|gif|pdf|docx|doc|xls "Note file will be uploaded when the form is submitted"If you would like your agent to request the loss runs on your behalf please check YesNoLOSSESLosses All losses/claims require a written description, including nature of injury cause and current status.Date of Occurance Date of Claim Amount Paid Description of Occurance or Claim Additional Loss Date of Occurance Date of Claim Amount Paid Description of Occurance or Claim Additional Loss Date of Occurance Date of Claim Amount Paid Description of Occurance or Claim Employee InformationClass Code Type of work # of Employees Hourly pay Est. Annual Payroll Class Code Type of work # of Employees Hourly pay Est. Annual Payroll Class Code Type of work # of Employees Hourly pay Est. Annual Payroll Class Code Type of work # of Employees Hourly pay Est. Annual Payroll Class Code Type of work # of Employees Hourly pay Est. Annual Payroll BenefitsAre Benefits Provided For All Eligible Employees YesNoGroup Health YesNo% Paid By Employer % of Participation Paid Sick Leave YesNo% Paid By Employer % of Participation Vacation YesNo% Paid By Employer % of Participation Retirement YesNo% Paid By Employer % of Participation Name of Health Care Provider Provide Name of Clinic, Physician, or Emergency Room for Work Place Injury Type Of WorkNEW CONSTRUCTION - next 3 lines should each total 100% Residential % Industrial % Commercial % REMODELING - next 3 lines should each total 100% Residential % Industrial % Commercial % REPAIR WORK - next 3 lines should each total 100% Residential % Industrial % Commercial % Describe Your Operation Perform Exterior Work Over 3 Stories? YesNoAnnual Gross Receipts Sub Out Cost Describe The Type Of Work Sub-Contracted Average Hourly Wage Full Time Average Hourly Wage Part Time Application Information THIS APPLICATION CONTAINS THE INFORMATION NEEDED TO START YOUR POLICY. IN SOME CASES IT MAY BE NECESSARY TO TRANSFER THIS INFORMATION TO ONE OR MORE CARRIER SPECIFIC FORMS. IF THAT IS NECESSARY WE WILL COMPLETE THEM FOR YOU AND SIGN ON YOUR BEHALF WITH THE INFORMATION FROM THIS APPLICATION. CLIENT AGREES TO INDEMNIFY AND HOLD HARMLESS TOP CONTRACTORS INSURANCE, ANY OF ITS EMPLOYEES AND AGENTS, ALONG WITH ANY OF ITS AFFILIATED COMPANIES FROM AND AGAINST ANY AND ALL CLAIMS ARISING OUT OF OR RELATION TO ANY ALLEGED FAILURE TO ACT ON THE PART OF THE CLIENT WHICH RESULTS IN ANY CLAIM, DEMAND, ACTION, OR CAUSE OF ACTION AGAINST TOP CONTRACTORS INSURANCE SERVICES INC, OR ITS AFFILIATED COMPANIES. VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank
