NJRHA Application

True & Assocaites/NJRHA Workers Compensation Safety Group Application Please answer every question.

If you have any questions about the application call Frank Purdue at 908-379-2306.

Company Name (*)

Company Address (*)

Key Contact Person

Phone Number

Email Address

Federal Tax ID Number

Policy Effective Date

Type of Entity

Owner(s) and % of Ownership:

, % of Ownership:

, % of Ownership:

, % of Ownership:

, % of Ownership:

Will the owner be included for coverage under the Workers Compensation Policy (LLC's, Sole Proprietors or Partnerships apply to this question)
 Yes No

Number of Employees - Full Time

Number of Employees - Part Time

Annual Payroll by Class Code 9079 Restaurant and 8810 Clerical (this would only include a full time bookkeeper)

Class Code 9079

Class Code 8810

Experience Modifier

Four years of Loss Runs, current and 3 prior years

Does your present policy provide a managed care credit?

 Yes No --If yes, what percentage are you getting:

Does your present policy provide a scheduled credit?

 Yes No --If yes, what percentage are you getting:

Does your present policy provide a dividend at the end of the year for a good loss ratio?

 Yes No --If yes, what was the dividend percentage of premium returned last year?

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