Insurance WC Renewal Proposal

INSURANCE WC RENEWAL PROPOSAL

Applicant / Insured Information

Policy & Proposal Summary

Policy Number:    Policy Type:

Current Policy Period From: to .

Proposed Renewal Period From: to . Proposal valid through: .

Payroll & Classification Summary (Estimated)

Provide estimated annual payroll by classification. Premiums are estimated and subject to audit at policy end.

Experience Modification & Loss History

Experience Modification Factor (EMR):   Last three years loss run attached:

Premium Calculation (Estimated)

Manual Premium (subtotal):

Adjustment for Experience Mod:

Premium Before Surcharges:

State Assessments & Fees:

Total Estimated Annual Premium:

Minimum Earned Premium (if applicable):

Deductible / Retention Options

Proposed Deductible Options (select applicable):
No deductible (standard premium)
Per-claim deductible amount:
Aggregate deductible:

Coverage Options & Endorsements

Employer's Liability Limit:

Include Voluntary Compensation Endorsement:   Include USL&H / Jones Act coverage (if applicable):

Exclusions & Special Conditions

Standard policy exclusions apply. Special underwriting conditions that may affect final acceptance include, but are not limited to: subcontractor usage, leased employees, high-hazard operations, and unreported prior losses. Insurer reserves the right to amend premiums, impose exclusions, or require corrective action upon review.

I acknowledge receipt of the exclusions summary and understand coverage will be subject to full policy terms.

Claims Reporting & Audit

Claims should be reported immediately to the designated claims contact. Failure to timely report may affect coverage. Provide preferred claims contact:

Applicant authorizes premium audit upon request by Insurer or its representative. Applicant agrees to retain payroll and employment records for audit verification. Authorization to perform audit:

Payment Terms & Plan Selection

Payment Plan Options (select one):
Pay in full at inception
Installment plan (subject to installment fees)
Electronic funds transfer (EFT)

Designated Payee / Beneficiary for Policy Notices

(Optional) Provide the name and relationship for any payee or beneficiary for policy notices or benefit payments where applicable.

Representation, Certification & Conditions

By signing below, Applicant certifies that all information provided in this proposal is complete and accurate to the best of Applicant's knowledge. Applicant acknowledges that this proposal is based upon representations and that material misrepresentation, omission or failure to disclose relevant facts may result in rescission, retroactive premium adjustment, or declination of coverage.

This Renewal Proposal is an offer to renew the policy on the terms stated herein. It is not a binder of insurance unless expressly indicated in writing. Final coverage, limits, endorsements and premium are subject to underwriting review, verification of payroll and exposures, completion of any requested inspections, and acceptance by the insurer.

Applicant authorizes the insurer to obtain loss history and other underwriting information from prior carriers and third-party administrators. Applicant understands that premiums are subject to audit and adjustment for actual exposures and classification changes.

Insurer Conditions

This Proposal is subject to the following conditions: completion of required inspections, satisfactory resolution of outstanding audits or claims investigations, receipt of signed authorization for premium financing (if applicable), and receipt of any required initial premium payment. Insurer reserves the right to withdraw or amend this Proposal prior to binding.

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