Specific ACORD 38s are available for applicants in these states.) (Applicant's Initials):. 18. ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST ...

THIS FORM MUST BE ATTACHED TO AN ACORD. THIS FORM ALONG WITH AN ACORD 130 WORKERS COMPENSATION APPLICATION CONSTITUTE AN APPLICATION FOR. The ACORD name and ...

ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? 2. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D). 17. ANY OTHER INSURANCE WITH THIS ...

PENALTIES INCLUDE. IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

ACORD WORKERS COMPENSATION APPLICATION. PRODUCER. PHONE. (A/C, No, Ext):. CODE: SUB CODE: AGENCY CUSTOMER ID. STATUS OF SUBMISSION. QUOTE. COMPANY. APPLICANT.

PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON. HOW TO SUBMIT A REQUEST TO US FOR A MORE ...

FEDERAL EMPLOYER ID NUMBER. NCCI ID NUMBER. OTHER RATING BUREAU ID OR STATE. EMPLOYER REGISTRATION NUMBER. STATUS OF SUBMISSION. BILLING/AUDIT INFORMATION.

Specific ACORD 38s are available for applicants in these states.) (Applicant's Initials):. 18. 17. SIGNATURE. PERSONAL INFORMATION MAY ...

CLAIMS. RECORD. TYPE. ACCTNG. INSPECTION. CONTACT INFORMATION. E-MAIL. MOBILE PHONE. NAME. The ACORD name and logo are registered marks of ACORD. SPECIFY ...

ATTACH THE LAST FOUR (4) EMPLOYERS QUARTERLY REPORTS OR IRS FORM 941. PLEASE EXPLAIN IF THE EMPLOYERS QUARTERLY REPORTS OR 941 IS NOT AVAILABLE.