DATE (MM/DD/YYYY)

WORKERS COMPENSATION APPLICATION

AGENCY NAME AND ADDRESS COMPANY:

UNDERWRITER:

APPLICANT NAME:

OFFICE PHONE: MOBILE PHONE:

MAILING ADDRESS (including ZIP + 4 or Canadian Postal Code) YRS IN BUS:

SIC:

PRODUCER NAME: NAICS:

CS REPRESENTATIVE WEBSITE
NAME: ADDRESS:
OFFICE PHONE
(A/C, No, Ext): E-MAIL ADDRESS:
MOBILE SOLE PROPRIETOR CORPORATION LLC TRUST UNINCORPORATED
PHONE: ASSOCIATION
FAX PARTNERSHIP SUBCHAPTER JOINT VENTURE OTHER:
(A/C, No): "S" CORP
E-MAIL CREDIT
ADDRESS: BUREAU NAME: ID NUMBER:
FEDERAL EMPLOYER ID NUMBER NCCI RISK ID NUMBER OTHER RATING BUREAU ID OR STATE
CODE: SUB CODE: EMPLOYER REGISTRATION NUMBER
AGENCY CUSTOMER ID:

STATUS OF SUBMISSION BILLING / AUDIT INFORMATION

QUOTE ISSUE POLICY BILLING PLAN PAYMENT PLAN AUDIT

BOUND (Give date and/or attach copy) AGENCY BILL ANNUAL AT EXPIRATION MONTHLY

ASSIGNED RISK (Attach ACORD 133) DIRECT BILL SEMI-ANNUAL SEMI-ANNUAL

QUARTERLY % DOWN: QUARTERLY

LOCATIONS
HIGHEST
LOC # FLOOR STREET, CITY, COUNTY, STATE, ZIP CODE

POLICY INFORMATION
PROPOSED EFF DATE PROPOSED EXP DATE RATING EFFECTIVE DATE ANNIVERSARY RATING DATE RETRO PLAN
(if applicable) (if applicable) PARTICIPATING
NON-PARTICIPATING
PART 1 - WORKERS PART 3 - OTHER DEDUCTIBLES AMOUNT / % OTHER COVERAGES
PART 2 - EMPLOYER'S LIABILITY (N / A in WI)
COMPENSATION (States) STATES INS (N / A in WI)
MANAGED
$ EACH ACCIDENT MEDICAL U.S.L. & H. CARE OPTION
VOLUNTARY
$ DISEASE-POLICY LIMIT INDEMNITY COMP
$ DISEASE-EACH EMPLOYEE FOREIGN COV
DIVIDEND PLAN/SAFETY GROUP ADDITIONAL COMPANY INFORMATION

SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

TOTAL ESTIMATED ANNUAL PREMIUM - ALL STATES

TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES TOTAL MINIMUM PREMIUM ALL STATES TOTAL DEPOSIT PREMIUM ALL STATES

$ $ $
CONTACT INFORMATION
TYPE NAME OFFICE PHONE MOBILE PHONE E-MAIL
INSPECTION
ACCTNG
RECORD
CLAIMS
INFO
INDIVIDUALS INCLUDED / EXCLUDED
PARTNERS, OFFICERS, RELATIVES ( Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.)
Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.
TITLE/ OWNER-
STATE LOC # NAME DATE OF BIRTH RELATIONSHIP SHIP % DUTIES INC/EXC CLASS CODE REMUNERATION/PAYROLL

ACORD 130 (2017/05) Page 1 of 4 © 1980-2017 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
STATE RATING SHEET # OF SHEETS AGENCY CUSTOMER ID:

STATE RATING WORKSHEET

FOR MULTIPLE STATES, ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM

RATING INFORMATION - STATE:

# EMPLOYEES ESTIMATED ANNUAL ESTIMATED
DESCR
LOC # CLASS CODE CATEGORIES, DUTIES, CLASSIFICATIONS FULL PART SIC NAICS REMUNERATION/ RATE ANNUAL MANUAL
CODE
TIME TIME PAYROLL PREMIUM

PREMIUM
STATE: FACTOR FACTORED PREMIUM FACTOR FACTORED PREMIUM
TOTAL N/A $ $
INCREASED LIMITS $ SCHEDULE RATING * $

DEDUCTIBLE * $ CCPAP $
EXPERIENCE OR MERIT
MODIFICATION $ STANDARD PREMIUM $

TERRORISM N/A $ PREMIUM DISCOUNT $

CATASTROPHE N/A $ EXPENSE CONSTANT N/A $

ASSIGNED RISK SURCHARGE * $ TAXES / ASSESSMENTS * N/A $
ARAP * $ $
* N / A in Wisconsin
TOTAL ESTIMATED ANNUAL PREMIUM MINIMUM PREMIUM DEPOSIT PREMIUM
$ $ $

REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

ACORD 130 (2017/05) Page 2 of 4

 AGENCY CUSTOMER ID:
PRIOR CARRIER INFORMATION / LOSS HISTORY
PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS LOSS RUN ATTACHED
YEAR CARRIER & POLICY NUMBER ANNUAL PREMIUM MOD # CLAIMS AMOUNT PAID RESERVE

CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS
GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS: MANUFACTURING - RAW MATERIALS, PROCESSES, PRODUCT, EQUIPMENT; CONTRACTOR - TYPE
OF WORK, SUB-CONTRACTS; MERCANTILE - MERCHANDISE, CUSTOMERS, DELIVERIES; SERVICE - TYPE, LOCATION; FARM - ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS.

GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES Y/N
1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT?

2. DO / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR
TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)

3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?

4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?

5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?

6. ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)

7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If "YES", payroll for this work must be included in the State Rating Worksheet on Page 2)

8. IS A WRITTEN SAFETY PROGRAM IN OPERATION?

9. ANY GROUP TRANSPORTATION PROVIDED?

10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?

11. ANY SEASONAL EMPLOYEES?

12. IS THERE ANY VOLUNTEER OR DONATED LABOR? (If "YES", please specify)

13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?

14. DO EMPLOYEES TRAVEL OUT OF STATE? (If "YES", indicate state(s) of travel and frequency)

15. ARE ATHLETIC TEAMS SPONSORED?

16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?

ACORD 130 (2017/05) Page 3 of 4

 AGENCY CUSTOMER ID:
GENERAL INFORMATION (continued)
EXPLAIN ALL "YES" RESPONSES Y/N

17. ANY OTHER INSURANCE WITH THIS INSURER?

18. ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)

19. ARE EMPLOYEE HEALTH PLANS PROVIDED?

20. DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?

21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If "YES", # of Employees:

23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS? (If "YES", please specify)

24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES?
IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S).

SIGNATURE
Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.)
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS
OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS
OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES
WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE
PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO
REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN
WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY
BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON
HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION.
(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.) (Applicant's Initials):

Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or
benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison. *Applies in MD Only.
Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.
Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be
presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or
telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows
to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and
the stated value of the claim for each such violation)*. *Applies in NY Only.
Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil
penalties.
Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a
false statement as to any material fact may be violating state law.
Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps,
or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss,
shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty
thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2)
years.
Applicable in UT: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for
disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a
crime and may be subject to fines and confinement in state prison.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
APPLICANT'S SIGNATURE (Must be Officer, Owner or Partner) DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER

ACORD 130 (2017/05) Page 4 of 4