HomeMy WebLinkAbout28872 / 77-23June 2, 1977 # 23 RESOLUTION
PURPOSE: TO APPLY FOR INCLUSION TN THE STATE WORKER'S
COMPENSATION POOL
I�7ITIATED BY: CITY ADMINISTRATTON
BE IT RESOLVED by the Common Council of the City �f Oshkosh
tnat the proper City officials are hereby au�.horized aiYd d�rectec3
to file the attached application with the State of Wisconsin for
inclusion of the City in the State worker's compensation pool.
S�I°i:1IT';'�D BY
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THE
WISCONSIN COMPENSATION RATING BUREAU
733 N. VAN BUREN STREET - MILWAUKEE, WISCONSIN 53202
APPLICATION FOR DESIGNATION OF AN INSURANCE COM AN
IN ACCORDA\CE WITH THE
WISCONSIN WORKER'S COMPENSATION REJECTED RISK POOL
IMPORTANT
COMPLETE IN ACCORDA\CE WITH INSTRUCTIONS. TYPE OR PRINT
THE UNDERSIGNED EMPLOYER IS UNABLE TO PURCHASE WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY
INSURANCE FOR HIS LIABILITY UNDER THE WISCONSIN �VORKER'S COMPENSATION LAW AND HEREBY APPLIES FOR
THE DESIGNATION OF AN INSURANCE COMPANY TO PROVIDE INSURANCE IN ACCORDANCE WITH THE WISCONSIN
C0�4PENSATION REJECTED RISK POOL.
NA�1E OF EMPLOYER:
(IF PARTNERSHIP, NAMES OF PART�ERS NUST BE GIYEN TOGETHER W'1TH TRADE NAME OF BUSINESS)
(IF lNDIVIDUAL, NAME OF INDIVIDUAL �fUST BE GIYEN TOGETHER W(TH TRADE NAME OF BUSINESS) �
P.O. ADDRESS
(NO.) (STREET) (70µ�N OR CITY) (COUNTY) (STATE) (ZIP)
LEGAL STATUS ❑ 1NDIVIDUAL ❑ PARTNERSHIP ❑ CORPORAZ'ION ❑OTHER
DATE BUSINESS OR OPERATION BEGAN
O��NERSHIP. THE OWNERS OF THIS LEGAL ENTITY A�ID THE PERCENTAGE OF OWNERSHIP OF EACH ARE:
NAME OF OWNER(S)
% OF INTEREST
PREVIOUS WORKMEN'S COMPENSATION INSURANCE_ HAVE YOU HAD A POLICY OF WORKMEN'S COMPENSATION INSURANCE IN
EFFECT DURING THE LAST THREE YEARS?
I�A�fE OF LAST INSURANCE COMPANY
POLICY NUMBER
EFFECTIVE DATE
U�PAID wORKER'S COMPENSATION INSURANCE PRE`11U�1. DO YOU OWE ANY BROKER, AGENT OR INSURANCE COMPANY ANY
UNPAID WORKER'S COMPENSATION 1NSURANCE PRE�1IUtii INCURRED WITHIN THE LAST 7"WO YEARS?
THE BOOKS AND RECORDS OF THE BUSINESS OR OPERATIONS hiAY BE EXAM1tINED AT
4. LOCATION OF ALL SNOPS, YARDS OR WORK PLACES. BY TO�VN OR CITY WITH STREET AND NUMBER
5. CO�IPLETE DESCRIPTION OF BUSINESS OR OPERATIONS
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6. CEHIItICAIIU� ur VrtK,qiw.�� �• --- -- - --
CLASSIFICATIOti PHRASEOLOGY
CLERICAL OFFICE EMPLOYEFS
OUTSIDE SALFSMEN
DRIVERS AtiD THEIR HELPERS
CODE I ESTIMATEDTOTALANNUAL
NO. REMUNERATIO`l
CO�iPLETE THE FOLLOWING IF A CORPORATION
NA`rfE AND TITLE OF EACH EXECUTIVE OFFICER:
TOTAL PREtitIUM SUBJECI� TO THE EXPERIENCE MODIFICATION
PRE�flli�t �fODIFIED TO REFLECT
EXPERIE\CE ASODIFICATION" OF
OTHER
pRE>f1U�S
CH�RGES
ril\1`fUvt PREMIUM 5
� ENTER NONE 1F EMPLOYER NOT SUBIECI' 7'O EXPERIENCE RATING
REQUESTED EFFECTIVE DATE OF INSURANCE
AGREEMENT B� APPLICANT
MANUAL RA7E PER SI00 I EStI�tATED ANNUAL
OF REMUNERATtON PREMIU�1
EXP. CONSTANT 0020
LOSS CONSTANT 0032
TOTAL ESTIMATED
ANNUAL PREMIUM
NOTE: THE EFFECTIVE DATE OF IKSURA`CE IS GOVERtiEU
BY THE RULFS OF THE REJECTED RISA POOL
THE L'�DESIGNED Eh1PLOYER HEREBY CER7'IFIES THAT NE HAS READ AND UNDERSTANDS 7'HE STATEMENTS II� "THIS APPLICA-
TIOV. FURTHER,�tORE, IN CO�SIDERATION OF THE ISSUANCE OF '['HE POL[CY OF INSURANCE, HE ALSO CERTIFIES THAT THE STATE-
DtEi�'TS I;� TH1S APPLICATIO�I ARE TRUE AND AGREES:
1. TO �1AINTAIN A CO�SPLETE RECORD OF ALL PAYROLL TRANSACf10NS IN SUCH FORM AS THE INSURANCE CO;�tPANY AtAY
REa+SONABLY REQUIRE AND THAT SUCH RECORD WILL BE AVAILABLE 70 THE COMPANY AT 7'HE DESIGNATED ADDRESS.
2. TO CO�fPLY SUBSTA.'`riLaL.LY ��'ITH ALL LA�VS, ORDERS, RULES AND REGULATIONS IN FORCE AND EFFECT h'IADE BY THE PUBLIC
AUTHORITIES RELATING TO THE �VELFARE, HEALTH AND SAFETY OF EMPLOYEES.
3. TO C0�1PLY VJITH ALL REASONABLE RECOMMENDATIONS MADE BY THfi INSURANCE COMPANY RELATIVE TO THE ��"ELFARE,
HEALTH AND SAFETY OF E�IPLOYEES.
(�'IOLA'I'lO�I OF A\�1' OF THESE AGREEME1�iTS MAY RESUL'I� IN CANCELLATION OF ANY POLTCY OF lNSURANCE ISSUED)
IB1:51�ESS NA�fE OF E�IPLOYER�
lDA7E OF APPLICATION)
STATEMENT OF THE PRODL;CER OF RECORD
(SIGNATURE)
(TITLE)
1, DO NEREBY CERTIFY THAT I A`i A LICENSED BROKER, AGENT, OF THE STATE OF
. I HAVE READ THE PLAN, HAVE EXPLAINED THE
PROVISIO�vS TO THE APPLICANT, AND HAVE INCLUDED IN THIS APPLICAT[ON ALL REQUIRED INFORMATION GiVEN TO h1E BY THE
APPLICANT. 1N THE EVENT THE POLICY IS CANCELLED OR A CHANGE iS MADE RESULTING IN A RETURN PRE�t1U`1 TO THE IN-
SURED, 1 AGREE TO RETUR:� THE UNEARNED COMMiSSION PORTION OF SUCH RETURN PRE�IIUM.
NkODUCER'S NA�tE STREET � CITY STATE
YIP CODE PRODUCER'S IRS OR SOCIAL SECURITY KWIBER PK(iDI:CER'S SIG\ATUKE
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