Business & Auto Insurance in Palatka Florida

Request for Quote for AMS Staff Leasing
Date
Federal ID #::
Address: (City, State, Zip)
Company:
Contact:
Phone:
Fax:
E-mail:
Web Site:
Are you currently using outside payroll services? Yes No
If Yes, who?
Annual Cost	$
Required Documents for Quote: Workers Compensation declairation page including rating schedule and annual payroll verification (941/940) by class code, or if with a leasing company, current invoice with codes broken out. Four years of Loss Runs Current State Unemployment Rating Page Gross Sales - previous year and current year Current Experience modification Worksheet Narrative on Insured's letterhead stating the nature of their business (past, present & future) in as much depth as possible Completed General Information Questionnaire
I acknowledge that I am requesting a quote from , exclusively representing AMS Staff Leasing. I further acknowledge that I have not requested a quote from another AMS Staff Leasing broker. Name: Date:
AMS Staff Leasing Client Application & Worksheet
MArketing Group & Number:
Contact Name:
Address: (City, State, Zip)
Phone:
Fax:
E-Mail:
I. Applicant Information Section
Proposed Contract Date:
AMS Customer Number:
FEIN#:
License #:
Client Name (Name all entities):
Client Address: (city, state, zip)
Phone:
Fax:
Primary Contact Name:
Phone or E-mail:
Secondary Contact Name:
Phone or E-mail:
Year Business Started:
Effective Date:
NCCI Experience Modifier:
Modifier Effective Date:
II. Location and Other Information
Pay Frequency:
Ship Day:
Pay Period Ending Day:
Check Day:
Shipping Method:
Bill For Shipping:	Yes No
Bill Minimum Fee:	Yes No
Multiple Shipping Locations:	Yes No
Shipping Cost:
Shipping Address 1:
Shipping Address 2:
Will Client utilize direct deposit?(Must pay by ACH withdrawl)	Yes No
Will Client print checks at their own location? (Must Pay by ACH Withdrawl and print checks on own payroll account)	Yes No
Username: (first name, last initial)
User Password:
Will Client need to:
Input Payroll	Yes No
Print Checks	Yes No
Print Invoices	Yes No
III. Additional Premises Information
Location #
Building #
Street
County
State
Zip

Location #
Building #
Street
County
State
Zip
IV. Nature of Business / Description of Operations on Premises
(Elaborate on past, present, and future jobs. Describe specific activity of all employees)
V. Revenue Rating Information
State:
Location #:
Classification / Description:
W/C Code:
W/C Rate:
Total Burden:
Estimated Annual PR:

State:
Location #:
Classification / Description:
W/C Code:
W/C Rate:
Total Burden:
Estimated Annual PR:
VI. Coverage History
Current WC Insurance Provider
Reason for coverage change (Please elaborate)
VII. General Information (Check box that applies)
Yes No N/A	1. Is the applicant a subsidiary of another entity or have any subsidiaries?
Yes No N/A	2. Is the applicant engaged in any other type of business?
Yes No N/A	3. Does the applicant get involved in any of the following operations: Dam Construction, including cofferdams and caisson building Levee or breakwater construction Subway or tunnel construction Railroad construction Blasting Environmental / pollution work Asbestos abatement work Trucking - interstate or transporting or disposing of hazardous waste Chemical, petrochemical process, oil/gas well and nuclear work Occupational disease exposure Offshore drilling Underground or coal mining of any type Wrecking or demolition of structures, vessels or building exceeding two stories in height Rocket or missile testing or launching Sawmills or logging Window cleaning in excess of two stories Bridge construction or painting Steel erection in excess of two stories Scaffold - leasing, erection or repair Sand or gravel digging Pesticide operations involving fumigation or tenting Crane operations Repossessing services
Yes No N/A	4. Does the applicant own, operate, or lease aircraft / watercraft? If yes, is it used in day to day operations?
Yes No N/A	5. Is there exposure to flammables, explosives, or chemicals? If yes, what type of protection and preventative measures are used?
Yes No N/A	6. Are there past, present or discontinued operations that involve storing, treating, discharging, applying, disposing or transporting of hazardous material? If yes, which ones? and what type of hazardous materials?
Yes No N/A	7. Is work performed underground or above 15 feet? If so, how deep is the confined space, or how high, and is tie off equipment used?
Yes No N/A	8. Is work performed on Barges, vessels, docks, or bridges over water? If yes, how often and what safety measures are in place?
Yes No N/A	9. Is group transportation provided? If yes, what type of vehicle and how many employees use the transportation?
Yes No N/A	10. Are any employees under 18 or over 60 years of age? If yes what are their job functions?
Yes No N/A	11. Are there part time or seasonal employees? How many?
Yes No N/A	12. Is there volunteer or donated labor?
Yes No N/A	13. Do employees travel out of state? How far and how long?
Yes No N/A	14. Is there current or past involvement with OCIP? What percent of annual revenues?
Yes No N/A	15. Are employee health plans provided?
Yes No N/A	16. Does the risk hire subcontractors? What percent?
Yes No N/A	17. Does the risk obtain Certificates of Insurance from all subcontractors? Please provide a copy of all certificates.
Yes No N/A	18. Does the risk require all subcontractors to carry primary limits equal to or greater than their own?
Yes No N/A	19. Is the risk named as additional insured on all subcontractor's policies?
Yes No N/A	20. Does the risk use written subcontractor agreements containing hold harmless / indemnity agreements in favor of the risk?
Yes No N/A	21. Does the insured verify that all subcontractors follow all industry requirements and applicable state and local codes?
Yes No N/A	22. Does the insured use hot tar in their business?
I declare that to the best of my knowledge the information provided in this application is true is true and acnowledge that the information in this Client Application will be supplied to the insurance company providing worker's compensation insurance coverage to AMS Staff Leasing. I understand that any person who knowingly and with intent to defraud any insurance company or another person, files an application for insurance or statement of claim containing any materially false information, or conceals fore the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY substantial} civil penalties.
Completed by:
Date:

5111 Crill Ave.
Palatka, Florida 32177

Phone:
386-328-4898
Fax:
386-328-9712