Risk Transfer Initial Inquiry Service Self-Insured WCA Stop Loss

Our risk transfer initial inquiry service is available to service provider members seeking insurance and reinsurance solutions for their clients.

The service is designed to allow you to source potential providers and save time by providing initial information which will allow them to respond to you if they can assist you.

You can select which providers you wish to send the information to once you have completed the information below.

You can choose to provide as little or as much information as you wish but the more detail that you provide will allow a more detailed response.

Once a provider has expressed interest then in most cases you will be required to supply a more detailed application as required by each provider.

Submit your Inquiry

Client Information

Are there any states in which the applicant operated, but is not qualified to self-insure?

About the Cover

Employees

Are any employees subject to

Long-shore and harbor Workers' Compensation Act?
Jones Act?
Federal Employer's Liabilitiy Act?
Any other Federal Acts Exposure?
Does the insured have any part-time or leased employees?
Does the insured have any employees under the age of 18 or over the age of 60?
Does applicant have any foreign operations or employees who travel to foreign countries?

About the Company

Does applicant own, lease, or charter watercraft?
Does applicant own, lease, or charter aircraft?
Does applicant have any OSHA violations in the past 5 years?
Does applicant have any occupational disease exposure? (Includes: asbestos, silica dusts, toxins, injurious or haxardous substances, compounds or chemicals, fumes, radiation, communicables diseases and any other O.D exposures)
Does applicant manufacture, produce, refine, store, distribute or transport gase, gasoline or flammables?
Does applicant perform any underground, subaqueous or tunneling operations?
Does applicant do any wrecking, dismantling or demolition work?
Does the applicant's operations involve exposure to height or to burns?
Does the applicant subcontract any work to others?

Company Services Information

Loss Prevention Services

Claims Administration

Large Loss Experience (last 5 years)

Please list claims for the last 5 years which exceed 50% of the specific deductible and state whether they were an individual or multi-person claim.

Year Cause of Loss or Description of Disease Expected Total Paid Indemnity Expected Total Paid Medical Expected Total Paid Legal Total Expected Paid Multiple Claimant (Yes/No)
Add New Claim