Call KBS from 8:30 AM - 6:00 PM EST for assistance with any part of this application.  You will
receive an email confirming our receipt of your application and a quote should be available within
48 hours (sometimes even the same day!).  We will notify you of any delays or if additional
information is required to proceed.

Loss Runs (i.e. print-outs from your WC Insurance Company showing any losses or confirming no
losses) for the past three years can be very important in obtaining quotes, especially for large
companies.  Quotes released without loss runs are usually contingent upon providing loss runs that
confirm your representations about losses.  Therefore, please fax or overnight 3-year loss runs
to KBS whenever possible.  KBS Fax Number: 914-636-0802

To obtain Loss Runs, call your insurance company (NOT your agent).  Insurance carriers have a legal
obligation to provide loss runs to you within a specified time period.  Or, you can have KBS obtain
loss runs on your behalf by granting us authority below and providing complete policy information
(insurance company, policy number, effective date).

Finally, in order to provide you with more definitive quotations and  a proposal that helps you compare
your choices, please fax KBS the Declarations Pages of your current W.C. policy (also sometimes
called the "Information Pages" or "Face Pages").

Please note that no insurance is bound pending insurance carrier approval.  

Proceed to Application        Return to  Applications Pg. or  Client Services

 

 

 

Workers Compensation Application

Named Insured: 

Phone:        Fax:  

Type of Organization:

Federal Employer ID Number:

Contact Person:  
Title:  

E-mail:  

Year Established:     (If less than 3 years, describe experience)

Owners / Exec. Officers: (names, titles, % ownership, and birth dates)

Number of Locations:

States Where You Have Offices: 

Complete Addresses of all Locations: (if more than one, indicate HQ)

Describe Operations other than Same-Day, Local Delivery:   check if "none"

Name/Describe any other businesses you own or manage:

Name/Describe any formerly-owned businesses:

Describe hiring standards, guidelines, and procedures for Delivery Personnel:
For example, age and vehicle standards, MVR checks and standards, experience, training, etc.

Do you have an employee health insurance plan?     Yes    No

Describe all safety programs, training, meetings, incentives: 
Attach copies of any written materials


Compensation Information: (complete for all classes, regardless of coverage)

State #1

 Classification Total Number Number  Part-Time Empl or IC? Annual 'Payroll'/1099
Drivers of Your Vehicles $
Owner-Operators $
Bikers $
Walkers $
Outside Sales $
Executive Officers $
Administrative / Office $
Other: (specify below) $

State #2

 Classification Total Number Number  Part-Time Empl or IC? Annual 'Payroll'/1099
Drivers of Your Vehicles $
Owner-Operators $
Bikers $
Walkers $
Outside Sales $
Executive Officers $
Administrative / Office $
Other: (specify below) $

Claims Information:
1.  Experience Modification Factor: 
2.  Check box if no losses for past 3 years:    Note: loss runs may still be necessary
3.  Check box if Loss Runs are being faxed to KBS:  
4.  Check box to authorize KBS to obtain Loss Runs for you:
5.  Unless KBS is obtaining Loss Runs, please complete the table below:

 Year No. of Claims Total Incurred Losses    (including Reserves)
$
$
$
$

 Current & Prior Insurance Information:     Check box if none

 Year  Insurance Company  Policy Number  Expiration Date  Premium
$
$

 Do you wish to cover Executive Officers or Partners?    Yes     No
We strongly recommend coverage unless there is adequate health, disability, and life
insurance in place.  The rate is low, so insurance for job-related injury is inexpensive. 

Notes / Comments:

Thank you for turning to KBS.  Be sure to provide the documents we
requested at the top of this page.  We will get back to you soon!

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                                        Return to Applications (do NOT submit)
                                        Return to Client Services (do NOT submit)
      

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KBS International Corp.                                                        
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914-636-0802 fax
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