Workers Compensation and Employers Liability Proposal

Transcription

1 Workers Compensation and Employers Liability Proposal Prepared for: 6752 Camp John Rd Millington TN, Proposed by: Bobbitt & McGhee Proposed with: Frank Winston Crum Insurance This document is a proposal of insurance for the applicant indicated above. It is not to be used as proof of coverage. This premium indication is meant to be an estimate subject to successful completion of any applicable applications and/or questionnaires, however, our carriers will always have the final approval on all accounts. Coverage cannot be requested without all information. 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 Tennessee Total Estimated Annual Premium by State $3, Down Payment %: Down Payment Amount: # of Installments: Agent Commission %: Payment Instructions: Total Estimated Annual Premium $3, TRIA/Terrorism and Surcharges (State/Other) Included Payment Terms and Instructions 25% $ % We will need the following signed documents in order to bind: The Acord 130 signed by insured and agent (FL accounts must use the Acord 130FL and must be notarized) Signed Proposal Pages Inclusion/Exclusion form (if required) Currently Valued Loss Runs for the prior 3 years Signed Supplemental Completed Direct Draft form and copy of a voided check Payment Terms are stated above. Installments are consecutive monthly. Quote is only valid until the effective date

3 Workers Compensation and Employers Liability Proposal State by State Breakdown Proposed with: Frank Winston Crum Insurance Effective Date: 5/12/2015 Part I Workers Compensation Insurance (Coverage A and C) Statutory Coverage as provided by the following state: TN 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: TN 6752 Camp John Rd Millington TN, Class Code Description Rate Premium Basis (Rate per $100 of Exposure) 0042 Landscape Gardening 6.66 $41, Total Estimated Annual Premium $3, 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?: Yes 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 Bobbitt & McGhee of Memphis, TN (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: Landscape What is the max height, in feet, of work performed above ground level? (i.e. using ladders, scaffolding, lifts, etc.): 6.00 What is the percentage of work subcontracted out?: 0.00 Does the insured perform any tree trimming or removal exposure?: No Does the insured provide any snow removal on public roads or highways?: No Does the insured perform any roadside beautification or maintenance?: No How many vehicles do they have?: 1 How many drivers do they have?: 1 What is the maximum number of employees that would travel in one vehicle at a time?: 2 Is there any casual or day labor used?: No Applicant Signature Date