Applicant
Applicant Name:
	Enter complete legal name of employer
Requested Effective Date:	*

Class Code EZ Add If you know the class code to assign to this quote, you may enter it and click Add. NOTE: EZ Add utilizes the class code's primary phraseology. To view alternate phraseologies for a class code, use the Search feature below. Class Code: Search Criteria To locate a class code, enter either a class code or keyword and click Search. Class Code: Keyword: Search Type: Contains Begins With * Search Results Double-click on a class code in the search results to add it to the list of selected class codes. To view alternate phraseologies, click the symbol next to the class code. No Data to Display Selected Class Codes Listed below are the class codes that you have selected for this quote. To edit, click inside of the cell that you would like to edit. NOTE: All class codes are subject to verification by the NCRB.   ApplicationClassCodeId Code Phraseology Payroll If Any Employees USL&H Rate UseEmployees AllowUserRate CordCharge USLHApplies     Workers Compensation Class Code Lookup

Experience Modification

Listed below is the Experience Modification and ARAP associated with this quote. Effective 4/1/10, the ARAP factor is no longer applicable when the experience mod factor is less than 1.01. Contact the NCRB Information Center for additional information.

Experience Modification:  * ARAP:  *

Coverages

Limits of Liability: By default, standard limits of liability apply to this application. If you would like to request increased limits of liability, select one of the increased limits options below. Bodily Injury Bodily Injury Bodily Injury By Accident By Disease By Disease Per Accident Per Employee Policy Limit Standard Limits $100,000 $100,000 $500,000 Increased Limits                 By selecting to increase your liability limits, this will increase the total amount of premium. $500,000 $500,000 $500,000 $1,000,000 $1,000,000 $1,000,000 Sole Proprietor And Partner Inclusion: Are sole proprietor wages included? Yes No Are partners wages included? Yes No If yes, how many partners? * Are members of the LLC included? Yes No If yes, how many members? *