Integrated MediComp Worker's Compensation Application
Please fill in all fields
NAME OF GROUP
GROUP HEALTH NUMBER
DATE (MM/DD/YY)
Will this Workers' Compensation Application be integrated with a
Blue Cross Small Group health plan?		 Yes No (if yes, please continue)
BROKER INFORMATION
WRITING BROKER'SS NAME BROKER LICENSE NO.
BROKER'S ADDRESS
GENERAL AGENT LICENSE NO.
 BROKER'S EMPLOYER I.D.NO.
CITY/STATE/ZIP
 PHONE NO.
 FAX NO.
COMPANY INFORMATION
NAME OF COMPANY AND D.B.A.
 YEARS IN BUSINESS
Individual Partnership Corporation Subchapter "S" Corp. Other (specify):
MAILING ADDRESS
 FEDERAL EMPLOYER I.D. NO.
CITY/STATE/ZIP
 OTHER RATING BUREAU I.D. NO.
LOCATIONS
ADDRESS
CITY/COUNTY/STATE/ZIPCODE
1 1
2 2
3 3
POLICY INFORMATION
PROPOSED EFFECTIVE DATE
(MM/DD/YY)
PROPOSED EXPORATION DATE
(MM/DD/YY)
NORMAL ANNIVERSARY RATING DATE
(MM/DD/YY)
PART 1 (States)
PROVIDE THE LEVEL OF CONTRIBUTION BY EMPLOYER TOWARS PAYMENT OF HEALTH BENEFITS ON BEHALF OF THE EMPLOYEE
RATING INFORMATION
State
Loc
Class Code
Categories/Duties/Classifications
No. of Employees
Full-time
Part-time
Estimated
Annual Payroll
SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (All exposures checked above should be explained)
INDIVIDUAL INCLUDED / EXCLUDED
Partners, Officers, Relatives to be included or ecluded. (Remuneration to be included must be part of rating information section.)
Name
Date of Birth
Title / Relationship
Ownership %
Duties
Include / Exclude
Class Code
Renumer-
ation
1
2
3
4
5
PRIOR CARRIER INFORMATION / LOSS HISTORY
Provide information for the past 5 years and use remarks section for loss details. (Must have a minimum of 3 years loss runs attached.)
Year
Carrier
Policy No.
Annual Premium
Mod.
No. Claims
Amount Paid
Reserve
NATURE OF BUSINESS / DESCRIPTION OF OPERATION
Give comments and descriptions of business, operations, and products; Manufacturing - raw materials, processes, product, equipment; Contractor - type of work, sub-contractor; Mercantile - merchandise, customers, deliveries; Service - type, location; Farm - acerage, animals, machinery, sub-contracts.
GENERAL INFORMATION
Please explain all "Yes" responses in the Remarks section below.
(Remarks section is highlighted in red.)
1. Does applicant own, operate or lease aircraft / watercraft?
Yes No
2. Do operations involve storing, treating, discharging, applying, disposing
or transporting of hazardous material? (e.g., landfills, asbestos, wastes, fuel tanks)
Yes No
3. Any work performed underground or above 15 feet?
Yes No
4. Any work performed on barges, vessels, docks, or bridges over water?
Yes No
5. Is applicant engaged in any other type of business?
Yes No
6. Are subcontractors used?
Yes No
7. Any work sublet without certificates of insurance?
Yes No
8. Is a formal safety program in operation?
Yes No
9. Any group transportation provided?
Yes No
10. Any employees under 16 or over 50 years of age?
Yes No
11. Any employees over 60 years of age?
Yes No
12. Any part-time or seasonal employees?
Yes No
13. Is there any volunteer or donated labor?
Yes No
14. Any employees with physical handicaps?
Yes No
15. Do employees travel out of state?
Yes No
16. Are athletic teams sponsored?
Yes No
17. Are pre-employment physicals required?
Yes No
18. Any other insurance with this insurer?
Yes No
19. Any prior coverage declined/canceled/non-renewed (last 3 years)?
Yes No
INSPECTION CONTACT
PHONE NO.
ACCOUNT RECORDS CONTACT
PHONE NO.
REMARKS
PLEASE ENTER YOUR EMAIL ADDRESS: