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Pay As You Go Workers Comp Insurance
1-877-77-GoAIB 1-877-774-6242
Pay As You Go Insurance
Pay As You Go Solutions
Pay As You Go Application
Pay As You Go Application
Application
Application-General Data
Business Name
Type of Business
Please Choose
Sole Proprietor
Partnership
LLC
Corporation
S-Corp
Non-Profit
Joint Venture
Religious Org
Professional Assoc
Governmental Entity
Trust
Your Name
(required)
Email
(valid email required)
Website
Phone Number
(required)
Years in Business
Street Address
City
State
Zip
(required)
States You Do Business In
Federal Tax ID number or Social
Mulitiple Locations
List Addressses of all company locations:
Policy Info
Proposed Effective Date
States to be included in coverage
Preferred Coverage Amount
100,000/500,000/100,000
500,000/500,000/500,000
1mil/1mil/1mil
Rating Information
Workers Comp rates the policy based on the what the worker does. Breaking out each classs of worker ensures the proper rating on a per class basis. Example: Clarical Office Staff - 4 full time 2 part time payroll totaling x.xx.
Class of Worker
How Many Full and Part time
Estimated Yearly Payroll for this Class of worker
Class or Worker
How Many Full and Part time
Estimated Yearly Payroll for this Class of worker
Class of Worker
How Many Full and Part time
Estimated Yearly Payroll for this Class of worker
Class of Worker
How Many Full and Part time
Estimated Yearly Payroll for this Class of worker
Prior Carrier Loss History
Please list loss history from prior carrier.
Individuals to be included/excluded from coverage
Owner's Name
(required)
Owner's Birthdate
(required)
Owner's title
Member
Owner
President
Secretary
Tresurer
Vice-President
(required)
% of Ownership
(required)
Include or Exclude
Exclude
Include
(required)
Estimated Payroll
Owner's Name
Owner's Birthdate
Owner's title
Member
Owner
President
Secretary
Tresurer
Vice-President
% of Ownership
Include or Exclude
Exclude
Include
Estimated Payroll
Owner's Name
Owner's Birthdate
Owner's title
Member
Owner
President
Secretary
Tresurer
Vice-President
% of Ownership
Include or Exclude
Exclude
Include
Estimated Payroll
Nature of Businsess
Describe Business
Enter Loss History:
no loss history
General Informaiton
1.DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT?
Yes
No
2. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATION INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc.)
Yes
No
3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
Yes
No
4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
Yes
No
5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
Yes
No
6. ARE SUB-CONTRACTORS USED? (IF YES, GIVE % OF WORK SUBCONTRACTED IN RAMARKS SECTION)
Yes
No
7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE?
Yes
No
8. IS A WRITTEN SAFETY PROGRAM IN OPERATION?
Yes
No
9. ANY GROUP TRANSPORTATION PROVIDED?
Yes
No
10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
Yes
No
11. ANY SEASONAL EMPLOYEES?
Yes
No
12. IS THERE ANY VOLUNTEER OR DONATED LABOR?
Yes
No
13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
Yes
No
14. DO EMPLOYEES TRAVEL OUT OF STATE?
Yes
No
15. ARE ATHLETIC TEAMS SPONSORED?
Yes
No
16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
Yes
No
17. ANY OTHER INSURANCE WITH THIS INSURER?
Yes
No
18. ANY PRIOR COVERAGE DECLINE/CANCELLED/NON-RENEWED (Last 3 years)? Not Applicable in MO
Yes
No
19. ARE EMPLOYEE HEALTH PLANS PROVIDED?
Yes
No
20. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?
Yes
No
21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
Yes
No
22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?
Yes
No
23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS?
Yes
No
24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OWNED ENTERPRISES? IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBERS(S) IN REMARKS SECTION.
Yes
No
Remarks
Validation
What color is snow?
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Pay As You Go Insurance
Pay As You Go Solutions
Pay As You Go Application
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