Parallel Concepts Request

CCA Global Division

Renewal Effective Date*

Insured Business Name*

DBA

Entity: Corporation*

LLC

Individual

Corporation

Other

If Choose Other:*

Address*

Street Address* Address Line 2 City* State* Zip*

Contact Name*

Phone*

Email*

Current Carrier

Have you had claims within the last 4 years?

Please submit 4 years of currently valued loss runs from current/past carrier to [email protected]. Please describe recent claims.

Annual Revenue (est)*

Annual cost of subcontracted work (estimate)*

Experience Mod Factor

NCCI Risk ID

FEIN

Additional Locations

(All locations may be included within this section)

State

Workers' Compensation must be purchased directly from the following states: Ohio, North Dakota, Washington & Wyoming

Class Code

Installation Type

If applicable

Estimated Annual Payroll

# of Employees

Untitled

What % of payroll shown for installers is Sub Contract labor?

Are subcontractors required to have their own General Liability, Auto and Workers' Compensation insurance?

Are Certificates of Insurance required?

Is Group Transportation provided?

Do you have a written safety program?

Do employees travel out of state?

Do you lease employees to or from other employers?

Are employee health plans provided?

OFFICERS/PARTNERS

Name

Title or Position

Payroll

Code

Exclude

Untitled

Parallel Concepts Request

Workers' Compensation Application