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1001700 2008 137728 208 09-18-2015Page 3 of 4EA 2504.2 Rev. 07-2015 <br />Workers Compensation Worksheet <br />Describe in detail each type of work or service performed by employees <br />USE ADDITIONAL SHEETS IF NECESSARY <br />TO LIST ALL EMPLOYEES. <br />Description of Activities <br />Show the number of employees separately in each case <br />(e.g., carpentry, plumbing, gas furnace installation, etc.) <br />and the annual payroll <br />Number of <br />employees <br />Actual <br />Remuneration <br />last 12 Months <br />Estimated <br />Remuneration <br />for next <br />policy period <br />Class <br />Code <br />Number <br />Class <br />Description <br />Number <br />Rate <br />Per $100 <br />Estimated <br />Premium <br />Clerical Office Employees, not otherwise classified <br />(office workers - no outside or plant work)0 0 <br />Outside Salespersons 0 0 <br />Truck Drivers (no other duties)0 0 <br />Other Employees (describe in detail each type of <br />work or service performed) <br />Business Consultant 1 7,500 <br />Required to balance to risk minimum premium XXXXX <br />Total premium subject to experience modification XXXXX <br />Applicable experience modification XXXXX <br />Premium adjusted by application of experience modification XXXXX <br />Other premium charges XXXXX <br />Total estimated standard premium XXXXX <br />Premium discount (if applicable)XXXXX <br />Expense constant XXXXX <br />Employer's Liability - Limit of Liability <br />Bodily Injury by Accident $ 100,000.00 Each Accident ($100,000 minimum) <br />Bodily Injury by Disease $ 100,000.00 Each Employee ($100,000 minimum) <br />Bodily Injury by Disease $ 500,000.00 Policy Limit ($500,000 minimum) <br />Minimum premium $ <br />Deposit premium $ <br />Premium/Payment Information 05-17-2022 01:16 PM <br />Application taken: <br />Initials of agent or licensed staff person taking the application: <br />SFPP <br />Yes No <br />Payment 1 <br />Cash <br />Check <br />Amount <br />Paid $ <br />Check <br />Number <br />Payment 2 <br />Cash <br />Check <br />Amount <br />Paid $ <br />Check <br />Number <br />Credit Card <br />EFT <br />Reference Number Amount <br />Paid $0.00 <br />Credit from <br />other policy $0.00 <br />Balance <br />Due $0.00 <br />Total <br />Premium $402.00 <br />Important Notices <br />Attach a copy of Social Security Report (IRS 941) and State Unemployment Compensation Report for each of the last four quarters. <br />Attach copies of ALL 1099's (Including Names, Work Performed and Amount Paid) and certificates of insurance from all subcontractors. <br />Attach a copy of Election to Reject form for each employee who rejects Workers Compensation. <br />DocuSign Envelope ID: C91CBC16-495D-4832-812B-E650985A3B1B