Workers' Compensation Application-Step3

 The following information is required 
to obtain a quote

  • A completed acord workers compensation application

  • A completed Auto Dealers Compensation of California, Inc. New member application supplement

  • four year's prior loss experience 

COMPANY
 AD COMP

APPLICANT NAME:

INTERNET ADDRESS: 

MAILING ADDRESS:
(INCLUDING ZIP CODE)


YEARS IN BUSINESS:

INDIVIDUAL   
PARTNERSHIP   
CORPORATION   
SUBCHAPTER "S" CORP 
LIMITED CORP   
OTHER

CREDIT BUREAU NAME
FEDERAL EMPLOYER
 ID NUMBER:

POLICY INFORMATION

PROPOSED EFFECTIVE DATE:

PROPOSED EXP DATE:

PAYROLL  INFORMATION

STATE LOC CLASS CODE CATEGORIES ANNUAL PAYROLL
CA ALL 8810 Clerical $
CA ALL 8748 Sales $
CA ALL 8391 Other $
CA ALL 8991 Service Advisors $

OFFICER INFORMATION

Part1
PARTNERS, OFFICERS, RELATIVES TO BE INCLUDED OR EXCLUDED (Remuneration to be included must be part of rating information section.)

# NAME DATE OF BIRTH TITLE/
RELATIONSHIP		 OWNERSHIP %

Part 2
PARTNERS, OFFICERS, RELATIVES TO BE INCLUDED OR EXCLUDED (Remuneration to be included must be part of rating information section.)

# DUTIES INC/EXC CLASS CODE PAYROLL

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 ICY#:
CO:
POL ICY #:
CO:
POL ICY #:
CO:
POL ICY #:
CO:
POL ICY #:

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS

GIVE COMMENTS AND DESCRIPTION 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 YES NO EXPLAIN ALL "YES" RESPONSES YES NO
DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/
WATERCRAFT?		 ARE PHYSICALS REQUIRED 
AFTER OFFERS OF EMPLOYMENT
  ARE MADE?
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.)		 ANY OTHER INSURANCE WITH THIS INSURER?
ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-
RENEWED (LAST 3 YEARS)?  NOT APPLICABLE IN MO
ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? ARE EMPLOYEE HEALTH 
PLANS PROVIDED?
IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS? IS THERE A LABOR INTERCHANGE WITH ANY
  OTHER BUSINESS/
SUBSIDIARY?
ARE SUB-CONTRACTORS USED? (IF YES, GIVE% OF WORK SUBCONTRACTED) DO YOU LEASE EMPLOYEES 
TO OR FROM OTHER EMPLOYERS?
ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.? DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?
IS A WRITTEN SAFETY PROGRAM IN OPERATION? ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS?
ANY GROUP TRANSPORTATION PROVIDED? ANY UNDISPUTED AND 
UNPAID WORKERS COMPENSATION PREMIUM 
DUE FROM YOU OT ANY COMMONLY MANAGED OR OWNED ENTERPRISES? 
IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S).
ANY EMPLOYEES UNDER 16 OR OVER 
60 YEARS OF AGE?		 CONTACT INFORMATION
ANY SEASONAL EMPLOYEES? INSPECTION
PHONE:
NAME: 
IS THERE ANY VOLUNTEER OR DONATED LABOR? ACCOUNTING RECORD
PHONE:
NAME: 
ANY EMPLOYEES 
WITH PHYSICAL HANDICAPS?
DO EMPLOYEES TRAVEL OUT OF STATE? CLAIMS INFO
PHONE:
NAME: 
ARE ATHLETIC 
TEAMS SPONSORED?

APPLICABLE IN TENNESSEE IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD, PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY 
INSURANCE COMPANY OR ANOTHER 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 THE 
PERSON TO CRIMINAL AND [NY:SUBSTANTIAL] CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR, VT; IN DC, LA, ME AND VA, I
INSURANCE BENEFITS MAY ALSO BE DENIED)

REMARKS

 

PLEASE SUBMIT AND PROCEED TO CALIFORNIA MOTOR CAR DEALER COMP PLAN, INC. NEW MEMBER APPLICATION SUPPLEMENT

 
(LINK PROVIDED ON CONFIRMATION PAGE AFTER SUCCESSFUL SUBMISSION OF ACORD APPLICATION)

FOR ASSISTANCE CALL RANDY FOSTER (800) 936-7837

Step 1

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