Submission Requirements

1. New Submission Requirements

• Minimum annual premium of $5,000.

• Written Safety and Loss Control/AWAIR program.

• Commitment to develop a written Return-to-Work program including the identification of light duty positions.

• Demonstrates a good attitude toward safety and providing a safe working environment.

• Willingness to work with the Loss Control Department.

• One year in business or past experience if a new operation.

2. Information Required for a Premium Indication

• A fully completed Workers Compensation Application (Acord 130).

• Five year loss runs (valued within the last ninety (90 days).

• Detailed explanation of each claim over $25,000, including any corrective action taken.

• The most recent promulgated Experience Rating Modification Worksheet.

• A detailed description of the prospect’s operation.

• Confirmation that the prospect has a written Safety and AWAIR program.

• Confirmation that prospect has formal Return-to-Work program with light duty positions identified, or a willingness to implement a formal Return-to-Work program.

TBG Submission Requirements

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