Workers Compensation and Employers Liability Proposal

Transcription

1 Workers Compensation and Employers Liability Proposal Prepared for: 13 N. East Blvd Vineland NJ, Proposed by: Joseph J. Schipsi, Inc Proposed with: NorGUARD Insurance Company This document is a proposal of insurance for the applicant indicated above. It is not to be used as proof of coverage. All proposals should be considered an estimate and are subject to change based on accurate underwriting information received, changes in state rates, experience modifications, or any other items by jurisdictions that have control over such items.

2 Workers Compensation and Employers Liability Proposal Proposal Summary States Included in Coverage Total Estimated Annual Premium by State New Jersey $14, Down Payment %: Down Payment Amount: # of Installments: Agent Commission %: Payment Instructions: Total Estimated Annual Premium $14, TRIA/Terrorism and Surcharges (State/Other) Included Payment Terms and Bind Instructions 10% $1, % We will need the following items in order to bind: The Acord 130 signed by insured and agent. Signed Proposal Pages. Inclusion/Exclusion form. Currently Valued Loss Runs for the prior 3 years or the Report of Claims form, if approved by an underwriter Down payment via the Completed ACH form (attached) and copy of voided check to verify account information (no temporary or cashier's checks) Payment Terms are stated above. Installments are consecutive monthly. Quote is valid until the Effective date and is subject to pending rate changes. Quote subject to employees paid by W2.

3 Workers Compensation and Employers Liability Proposal State by State Breakdown Proposed with: NorGUARD Insurance Company Effective Date: 02/07/2017 Part I Workers Compensation Insurance (Coverage A and C) Statutory Coverage as provided by the following state: NJ Coverage includes Medical and Loss of Income Benefits for injuries arising out of a work related injury. Part II Employers Liability Insurance (Coverage B) Limits of Insurance Bodily Injury By Accident $ 100,000 Each Accident Bodily Injury By Disease $ 500,000 Policy Limit Bodily Injury By Disease $ 100,000 Each Employee Rating Information State: Name of Insured: Location of Insured: NJ 13 N. East Blvd Vineland NJ, Class Code Description Rate Premium Basis (Rate per $100 of Exposure) 2003 Bakery (Wholesale or Commercial) $150, Total Estimated Annual Premium $14, TRIA/Terrorism and Surcharges (State/Other) Included

4 Key Exposures Describe the business: PEO Temporary Employment Agency General Contractor Gun Shop Trucking Roofing Employee Leasing Check Cashing Pawn Shop _X_ None of the these Identify special operations: Food Delivery Subcontracts more than 40% of receipts Any 24 hour operation - Convenience Stores Owners (only) included for coverage without Health Insurance Live Entertainment Work above 15 feet in Height Underground work below 6 feet in Depth _X_ None of the these Identify coverages required: USLH Volunteers Managed Care Options Foreign Voluntary Repatriation Special Endorsements _X_ None of the these Does the insured have prior consecutive Workers' Compensation coverage for the past 2 years?: No How many Indemnity claims has the insured had for the past 3 years? (enter numbers only): 0 How many Medical Only claims has the insured had for the past 3 years? (enter numbers only): 0 Any losses in the past 3 years from the following?: Weapons Automobile or Truck Accidents Assault or Battery Employees < age 16 or > age 60 _X_ None Applicant Signature Date

5 Report of Claims Experience DATE: TO: FastComp.com, LLC FROM: (Applicantʼs Name) To the best of my knowledge, I have had claims, totaling $ (paid and reserved) within the past three (3) years. There are open claims. claims involved the employee losing time from work. I will provide company loss runs through Fastcomp Underwriters of Hudson, OH (City, State) I understand that my policy, if accepted, is subject to cancellation or non-renewal if the company loss runs show a discrepancy from the information stated herein. Signed, Name Title Applicantʼs Name

6 Insured Qualifier Question Results Applicant Signature Date

7 Questionnaire: Manufacturing Does machinery have point of operation guarding?: Yes Are lockout / tagout procedures in place?: No Do machines have proper ventilation / dust collection systems?: Yes Are employees required to use personal, protective equipment (glasses, gloves, respirators, etc.)?: Yes Is there any delivery of goods?: Yes Is there any casual or day labor used?: No Applicant Signature Date