Workers Compensation Submission

Workers Compensation Submission

Does the insured have an ex mod over 1.25?*

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Did work comp coverage lapse while employees were still on payroll?*

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Is the insured a general contractor (class B license), the subs out more than 25% of their work?*

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Are you seeking a mid-term quote?

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Are the insured's operations any of the following: roofing, trucking, assisted living facility, rehab center, farming, janitorial that is mainly residential, solar paneling?

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Select Agency Specialist*

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Agency Name*

Work Comp Quotes Submitted By *

Agent Phone Number*

Agent Email*

Is the a rewrite of an existing AccessPlus Policy?*

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Which additional policies will you be submitting?*

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Insured Contact Name*

Business Name*

Does the insured have a DBA?*

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Legal Entity*

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FEIN * MUST BE ACCURATE*

Insured Business Phone Number*

Insured Cell Number

Insured Fax Number

Insured Email Address*

Business Website*

Mailing Address*

Effective Date For New Policy*

Prior Insurance - Carrier Name*

Prior Insurance - Policy Expiration Date*

Expiring and/or Target Premium*

Nature of Business*

Year Business Was Established*

Number of Years Management Experience*

Briefly describe the details of the management experience:*

Has there been any lapse In coverage during the last year?*

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Experience Mod*

Any losses in the past five year?*

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How many location does the insured have?*

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Location #1 Address*

Location 1 How Many Class Codes Are There?*

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Location 1 - Class Code 1*

Location 1 - Class Code 1 Annual Payroll*

Location 1 - Class Code 1 Number of Employees Part Time*

Location 1 - Class Code 1 Number of Employees Full Time*

Location 1 - Class Code 2*

Location 1 - Class Code 2 Annual Payroll*

Location 1 - Class Code 2 Number of Employees Part Time*

Location 1 - Class Code 2 Number of Employees Part Time*

Location 1 - Class Code 3*

Location 1 - Class Code 3 Annual Payroll*

Location 1 - Class Code 3 Number of Employees Part Time*

Location 1 - Class Code 3 Number of Employees Full Time*

Location #2 Address*

Location 2 How Many Class Codes Are There?*

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Upload Acord 130 (for all location/class code information)

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Location 2 - Class Code 1*

Location 2 - Class Code 1 Annual Payroll*

Location 2 - Class Code 1 Number of Employees Part Time*

Location 2 - Class Code 1 Number of Employees Full Time*

Location 2 - Class Code 2*

Location 2 - Class Code 2 Annual Payroll*

Location 2 - Class Code 2 Number of Employees Part Time*

Location 2 - Class Code 2 Number of Employees Full Time*

Location 2 - Class Code 3*

Location 2 - Class Code 3 Annual Payroll*

Location 2 - Class Code 3 Number of Employees Part Time*

Location 2 - Class Code 3 Number of Employees Full Time*

How many officers are there?*

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Additional Information/Remarks

Loss Runs Attached*

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Upload Loss Runs

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Upload Prior Carrier Dec Page (if available)

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Advantage America

25359 Madison Ave,

102,

Murrieta, CA 92563

Phone. 877-217-3770

Email. service@advantageamerica.co