West Virginia > Workers Comp
Application For Workers Compensation Coverage BI-WCA - West Virginia
| Application For Workers Compensation Coverage Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-WCA 07/06 Application for Workers' Compensation Coverage New Business P o l i c y Nu m b e r Legal Business Name Telephone Mailing Address Street WC Trade or DBA Name Fax City WV State Tax number EESIC Code West V irginia Physical Locations Location # L o c a t i o n n a me S t re e t City County County State Applicant Information Quote Only Policy Change Return completed form to: BrickStreet Mutual Insurance P.O. Box 3064 Charleston, WV 25334 Fax: 304-926-1996 Proposed Effective Da te Contact Name E-mail Address ZIP Code Individual Partnership Corporation LLC Subchapter "S" Corp Other: Sta te Z i p Co d e FEIN or Social Security number Coverage Information Co m p l et e t h i s f o r m u s in g b lu e o r b la ck in k . 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 Name Title $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 Federal Coal Mine Health & Safety Act Coverage Surface Underground Mining Other Owner/Officer Information Social Security Number (mandatory) % Owned Electing Coverage Yes No Electing Coverage Yes No Electing Coverage Yes No Electing Coverage Yes No Estimated Annual Remuneration * $ Estimated Annual Remuneration * $ Estimated Annual Remuneration * $ Estimated Annual Remuneration * $ Name Title Social Security Number (mandatory) % Owned Name Title Social Security Number (mandatory) % Owned Name Title Social Security Number (mandatory) % Owned *See Instructions for reportable minimum and maximum wages for owners/officers C o m m o n O w n e r s h i p I n f o r m a t i o n ( L i s t a n y o wn e r s / o f f i c e r s w h o h a v e c o m m o n o w n e r s h i p i n o t h e r i n s u r e d b u s i n e s s e s ) C o mp l e t e E R M 1 4 a s r e q u i r e d Name Title B u s i n e s s Na m e % Owned P o l i c y Nu m b e r Name Name Title Title B u s i n e s s Na m e B u s i n e s s Na m e R a t i n g I n f o r ma t i o n WV Location # Class Code Categories, Duties, Classifications # of Employees Full time Part Time $ $ $ $ Estimated Annual Remuneration % Owned % Owned P o l i c y Nu m b e r P o l i c y Nu m b e r BrickStreet Mutual Insurance P.O. Box 3064 Charleston, WV 25334-3064 American LegalNet, Inc. www.FormsWorkflow.com BI-WCA Ch e c k G e n e r a l B u s i n e s s O p e r a t i o n s . Merchandising Construction Wholesale General Contractor Retail Packaging Distribution Delivery Repair Page 2 Residential two stories and under Steel Sub-Contractor Type _______________ Concrete Clear cutting Underground Survey On-Site Construction Coal Hauling Manufacturing Other: Underground Construction Masonry Commercial, industrial and dwellings over two stories Type of material used: Timbering De sc ri p t i o n o f O p er at i o n s Timbering/Logging Underground Surface Sawmill On- Site mine equipment repair On- Site mine equipment repair Long Distance Temporary Agency Mining Trucking Miscellaneous Local ( within 50 miles) PEO/Labor Leasing 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. B u s i n e s s A c q u i s i t i on I n f o r ma t i o n S u b m i t E R M 1 4 Did you acquire/purchase/merge this business? Attach copy of contract Yes If yes, list the required information below No Previous Owner's/Merged entity's name WV Workers' Compensation number/FEIN General Information 1. Does applicant own, operate or lease aircraft/watercraft? 2. Any work performed underground or above 15 feet? 3. Any work performed on barges, vessels, docks or bridge over water? G e n er al In f o r ma t i o n Date business was acquired/purchased/merged Explain all "yes" responses No No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 4. Is applicant engaged in any other type of bu siness? 5. Are subcontractors used? (Give percentage.) 6. Is a formal safety program in operation? 7. Is there any volunteer or donated labor? 8. Do employees travel out of state? 9. Is there interchange of labor with any other business/subsidiary? 10. Do you lease employees to or from another business? 11. Any unpaid workers compensation premium due to WCC from you or any commonly managed or owned businesses? Yes No Applicant's Signature & Title Producer's Signature Date 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 Co
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