BI-WCA 05/08 Application for Workers’ Compensation Coverage New Business Quote Only Applicant Information Policy Number WC Policy Change Legal Business Name Return completed form to: BrickStreet Mutual Insurance P.O. Box 3064 Charleston, WV 25334 Fax: 304.941.1152 Proposed Effective Date: Contact Name Trade or DBA Name Telephone: Fax: Mailing Address Street FEIN or Social Security number City County WV State Tax number State ZIP Code E e- mail address E E S I C Code Individual Partnership Corporation LLC Subchapter “S” Corp Other: West Virginia Physical Locations Location # Location N ame Street City County State Zip Code C o m p l e t e t h i s f o rm u s in g b l u e o r b l ac k in k. Coverage Information Employers Liability Limits – Please indicate choice $100,000* $300,000 $500,000 $500,000 $500,000 $500,000 $100,000 $300,000 $500,000 *No additional charge for this level of coverage $1,000,000 $1,000,000 $1,000,000 Each Accident Disease – Policy Limit Disease – Each Employee WV Broad Form Employers Liability Please Indicate Choice Yes No Name Title Owner/Officer Information Social Security Number (mandatory) % Owned Name Title Social Security Number (mandatory) Federal Coal Mine Health & Safety Act Coverage Surface Underground Mining Other Estimated Annual Remuneration * Electing Coverage Yes No $ Estimated Annual Remuneration * % Owned Electing Coverage Yes No Name Title Name Title Social Security Number (mandatory) Social Security Number (mandatory) % Owned $ Estimated Annual Remuneration * Electing Coverage Yes No % Owned $ Estimated Annual Remuneration * Electing Coverage Yes No $ Common Ownership Information (List any owners/officers who have common ow nership in other insured businesses) Complete ERM 14 as required Name Title Business Name % Owned Policy Number Name Title Business Name % Owned Policy Number Name Title Business Name % Owned Policy Number Rating Information WV Location # Class Code Categories, Duties, Classifications # of Employees Full time Part Time Estimated Annual Remuneration $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Check general business operations. Merchandising Construction Wholesale Retail General Contractor Residential two stories and under Packaging Distribution Delivery Sub-Contractor Type _______________ Commercial, industrial and dwellings over two stories Type of material used: Steel Concrete Timbering De s cr i p t i o n o f O p er at io n s Repair Timbering/Logging Mining Underground On-Site mine equipment repair Underground Survey Surface On-Site mine equipment repair Masonry On-Site Construction Trucking Local ( within 50 miles) Miscellaneous PEO/Labor Leasing Sawmill Clear cutting Long Distance Underground Construction Coal Hauling Temporary Agency Manufacturing Other: Describe your primary services or products, including your methods of operations and machinery used. Include raw and semi- finished materials used (attach additional documentation if necessary.) Note: It is important for you to provide as much information as possible for us to properly determine your correct classification. Attach additional information if needed. Business Acquisition Information Submit ERM 14 Did you acquire/purchase/merge this business? Attach copy of contract Yes If yes, list the required information below No G en e ra l In f o rm a t i o n Previous Owner’s/Merged entity’s name WV Workers’ Compensation number/FEIN General Information 1. Does applicant own, operate or lease Yes aircraft/watercraft? 2 Any work performed underground or above 15 Yes feet? 3. Any work performed on barges, vessels, Yes docks or bridge over water? 4. Is applicant engaged in any other type of Yes business? 5. Are subcontractors used? (Give percentage.) Yes No 6. Is a formal safety program in operation? Yes No 7. Is there any volunteer or donated labor? Yes No 8. Do employees travel out of state? Yes No 9. Is there interchange of labor with any other business/subsidiary? 10. Do you lease employees to or from another business? Yes No Yes Date business was acquired/purchased/merged Explain all “yes” responses No No No No No Applicant’s Signature & Title Date Producer’s Signature Date Agency ID Number American LegalNet, Inc. www.FormsWorkFlow.com Completing the BrickStreet Insurance Workers’ Compensation Application For assistance please call 1.866.45BRICK (1.866.452.7425) Applicant Information Please supply requested information. Federal Employer Identification or Social Security Number: Please be sure to provide your federal employer identification number (FEIN). If you have applied for a FEIN, but have not received one, please write applied for in the appropriate box, however, you must forward it at a later date. Sole Proprietors and partnerships that do not need a FEIN should provide the Social Security number(s) of the sole proprietor or partners. WV State Tax Number: Please be sure to provide your WV State Tax number. If you have applied for a WV State Tax number, but have not received one, please write applied for in the appropriate box, however, you must forward it at a later date. Proposed effective date: Please provide the date you want your workers’ compensation coverage to begin. This date is subject to the receipt of the completed application and any supplemental information we may need. Coverage Information Employers Liability: BrickStreet Insurance will provide Employers Liability insurance at the 100,000/500,000/100,000 level at no additional charge to eligible employers. Employers Liability insurance is also available at the 300,000/500,000/300,000 level, 500,000/500,000/500,000 level and 1,000,000/1,000,000/1,000,000 for an additional charge. WV Broad Form Employers Liability: This optional coverage which was formerly known as Employers’ Excess Liability Fund Coverage. It provides coverage for West Virginia Annotated Code §23-4-2 (d) (2) (ii) for an additional charge. Additional Information available at BrickStreet.com. Federal Coal Mine Health & Safety Coverage: This is optional coverage which was formerly known as Coal Workers’ Pneumoconiosis Fund Coverage. It provides coverage for work subject to the Federal Coal Mine Health & Safety Act of 1969 (30 USC Sections 931–942) for an additional charge. Owner/Officer Information Coverage for Owner/Officer is extended unless we receive election declining coverage Elections of Coverage for Owners, Partners, and Officers Sole Proprietors and Partners: Sole proprietors and partners of a duly formed partnership are required to be covered for worker’s compensation unless the employer elects in writing that these persons are not to be covered. You may elect out of coverage by checking the “No” box of the Electing Coverage section. If coverage is elected please include the actual estimated annual remuneration for each covered proprietor or partner. Please remember that if you choose not to cover yourself and are injured at work, BrickStreet Insurance will not provide coverage and other insurance may not cover your work-related disability or medical bills. Corporations: Corporate officers are required to be covered for workers compensation unless they elect in writing that these positions are not to be covered. Except for the offices of president, vice president, secretary and treasurer and members of board of directors who may elect not to have coverage, all other officers or assistant officers serving in a dual capacity (also doing work ordinarily performed by a worker or administrator who is not an officer) must be covered. Eligible officers may elect out of coverage by checking the “No” box of the Electing Coverage section. If coverage is elected please include the actual estimated annual remuneration for each covered officer. Please remember that if you choose not to cover yourself and are injured at work BrickStreet Insurance will not provide coverage and other insurance may not cover your work-related disability or medical bills. Limited Liability Companies: Members of Limited Liability Companies (LLC) are required to be covered for workers compensation unless they elect in writing not to cover the persons who are acting in the capacity of LLC manager, officer or member of the company. If coverage is elected please include the actual estimated annual remuneration for each covered member. Please remember that if you choose not to cover yourself and are injured at work, BrickStreet Insurance will not provide coverage and other insurance may not cover your work-related disability or medical bills. Common Ownership Information Please list all owners, partners, officers, and shareholders with more than a 50 % interest in any other business that operates in West Virginia. Submit completed ERM 14 with application. Rating Information Please list the categories and number of employees at each location and provide the total remuneration. Description of Operations A complete description of your business operations is necessary to classify your operations. If inadequate information is supplied, your policy could be misclassified. To prevent this from occurring, please supply in -depth information regarding your processes, the equipment used, and the final product you may produce. Pamphlets, brochures, and website address may be submitted. Business Acquisition Information If you purchased/merged with an existing business the previous employer’s experience may transfer to you. A copy of the acquisition/merger papers is necessary to properly make this determination. Submit completed ERM 14 with application. General Information Please complete the general information section of the application. Explain any “yes” responses. Retain for your records American LegalNet, Inc. www.FormsWorkFlow.com