McClain Agency LLC. Workers Compensation Initial Information Form
Complete Form Below and Click "Submit" when Done
Name of Company
Desired Effective Date
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Day
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Year
Address
Name of Contact & Title
Type of Entity
Please Select
Individual/Sole Proprietor
Corporation
LLC
Partnership
Other
If "Other" Please Provide Details
Does Applicant Own, Operate, or Lease Aircraft or Watercraft?
Yes
No
Does Applicant Travel or Work outside of the US on Business?
Yes
No
Are Seasonal, Donated, Volunteer, Temporary, or Leased Employees A part of the Operation?
Yes
No
Does Operation Include Employees Under Age 21 or Over Age 65?
Yes
No
Are Employees Responsible for Maintenance of Property, Buildings, or Removal or Ice/Snow?
Yes
No
State of Business
Other States of Operations (If Applicable)
Per Accident/ Per Employee/ Policy Limit
Please Select
100,000/100,000/500,000
500,000/500,000/500,000
100,000/100,000/1,000,000
500,000/500,000/1,000,000
1,000,000/1,000,000/1,000,000
Does Your Company have an Experience Modification Factor ?
Yes
No
If "Yes" Do you Know your Expirence Modification Rating Date?
Experience Modification Factor
Are there any persons you wish to have Excluded?
Yes
No
If "Yes" Please List Names and Titles of Each
Do you wish to apply a deductible
Yes
No
Does Your Company Have a Workplace Premium Credit?
Yes
No
Location(s) Address (es) Please List All That Apply
Number of Employees
Description of Operations
Estimated Annual Payroll
Payroll per Classification (e.g.) 20% Sales team 50% Labor 25% Customer Service Ect...)
Any Losses in hte past 3 years (If "Yes" Please Provide Details
Submit
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