Completed Excess Workers Compensation Application (A copy of the application that you have sent to other excess carriers will suffice.)

Include Current Year and 5 Prior Years:

• Total Gross Payroll (copies of final audits are preferable)
• Total Gross Losses (indemnity, medical and expenses), paid and reserved
• Details of any single claim reserved over $50,000
• Currently valued Loss Runs
• Details of any watercraft or aircraft currently owned, operated, leased or chartered
• Estimated total gross payroll, by classification, for the upcoming policy year

Please notify us when you receive quotations / retentions from the excess workers compensation carriers and what lower retention options you wish us to quote.