Renewal Application

Member Information

Insured Name

Contact Name

Address

Street Address Address Line 2 City State ZIP Code

List of Principals

Name	City/State	Title	Is Principal to be covered under Workers Compensation coverage? (Yes/No)

Payroll Information

Payroll Information for the upcoming renewal period. (Kansas Only) ** Include Officers if they are to be covered **

Trucking, NOC All Employees & Drivers - Class Code 7219

Estimated Renewal Payrolls	Number of Employees

Auto Service/Repair Center - Class Code 8380

Estimated Renewal Payrolls	Number of Employees

Clerical - Class Code 8810

Estimated Renewal Payrolls	Number of Employees

Clerical - Class Code 8810

Estimated Renewal Payrolls	Number of Employees

Sales - Outside - Class Code 8742

Estimated Renewal Payrolls	Number of Employees

Store: Wholesale, NOC - Class Code 8018

Estimated Renewal Payrolls	Number of Employees

Mail or Package Delivery - Class Code 7231

Estimated Renewal Payrolls	Number of Employees

Iron or Steel Scrap Dealer and Driver - Class Code 8265

Estimated Renewal Payrolls	Number of Employees

Warehouseman - Class Code 8292

Estimated Renewal Payrolls	Number of Employees

Storage/Warehouse – Furniture & Driver - Class Code 8293

Estimated Renewal Payrolls	Number of Employees

Building-Operations & Clerical - Class Code 9012

Estimated Renewal Payrolls	Number of Employees

Building-All Other Employees - Class Code 9015

Estimated Renewal Payrolls	Number of Employees

Please add any other classification that is appropriate to your operations.

Input Estimated Renewal Payroll Total:

Total Number of Employees

# of Part Time Employees

# of Seasonal Employees

# of Employees Under Age 16

# of Employees Over Age 60

If you have any volunteer or donated labor, please describe their duties:

Please list affiliated companies, subsidiaries and divisions to be included in the program, if any.

Name	Principal Address (City, State, Zip)	Type of Business

Vehicle Information

Number of Employee drivers:

Number of Owned or Leased Vehicles

Passenger Cars

Van/Trucks:

Tractors:

Trailers:

Describe Applicant’s Use of Trucks:

Type of Goods Hauled:

Radius of Travel:

Primary States:

Average Mileage:

Maximum Mileage

Average Number of Persons per Vehicle:

Maximum Number of Persons per Vehicle:

Do you have operations involving the loading, unloading, repair or constructions of watercraft or vessels including work performed on barges or docks?

Do you have any foreign operations or employees who travel to foreign countries?

Are you engaged in the manufacturing, production, refining, storage, distribution or transportation of gases, gasoline or flammables?

Do you haul any hazardous waste or materials?

Are you engaged in the manufacturing, handling, transportation, distribution, or storage of explosives?

Have you been cited for any OSHA violations?

Do you provide any transportation of employees to or from the workplace?

Do you now (or have future plans to) own, lease, or charter watercraft or aircraft?

Risk Management Information

Do you use independent owner/operators?

If Yes, how many?

Have you included these owner/operators in your payroll estimates above?

Please provide a list of owner operators who are to be covered by KTRMG.

If you have not included them in your payroll estimates, do you require owner/operators to purchase their own statutory workers compensation insurance company or sign a statement that you are not providing coverage?

Do you keep a copy of this Certificate of Insurance on file?

Are owner/operators allowed to carry Occupational Accident coverage in place of Workers Compensation coverage?

If yes, please provide names of owner/operators

Do you lease employees to another firm?

Explain

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

Name

First Last

Date

Title

Member Information

Payroll Information

Vehicle Information

Risk Management Information

(844) 804-1789