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Kentucky AGC Self Insurers' Fund
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Login
Members
Audits
Make a Payment
Dividends
Forms
Join The Fund
Agents
Online Quote
Write for The Fund
Forms
Claims
Report an Incident
Claim FAQs
Safety
Safety Resources
Safety Blog
About
Associations
The Fund
FAQs
News
Contact
Department Contact Info
Contact Us
Login Help
General Information
Legal Name of Business
(Required)
FEIN
(Required)
Owner/Officer(s)
(Required)
Name
Title
Contact Name
(Required)
Contact Phone & Fax
Phone
Fax
Contact E-mail Address
Physical Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Is Mailing Address same as Physical
(Required)
No
Yes
Mailing Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Payroll & Premium Contact
(Required)
Claims Contact
(Required)
Safety Contact
(Required)
Type of Entity
(Required)
Corporation
LLC
Other
Partnership
Sole Proprietor
Date Business Started
(Required)
MM slash DD slash YYYY
Years of Operation-Related Experience
(Required)
Confirmed membership with the following association
(Required)
Select An Association
Associated General Contractors of Kentucky
Associated General Contractors of Western Kentucky
Builders Exchange of Kentucky
Home Builders Association of Kentucky
Kentucky Association of Highway Contractors
Kentucky Association of Master Contractors
Kentucky Crushed Stone Association
Local Chapter (if applicable)
Description of Operations*
(Required)
Do you have an Insurance Agent?
(Required)
No
Yes
Current Agent/Broker
(Required)
Insurance Agency
(Required)
Agent Phone & Fax
Phone
Fax
Agent E-mail Address*
(Required)
Current/Previous Insurance Information
Current/Previous Insurer?
(Required)
No
Yes
Current/Previous Insurer Name
(Required)
Annual Premium
Policy Period Effective Date
(Required)
MM slash DD slash YYYY
Policy Period Expiration Date
(Required)
MM slash DD slash YYYY
Proposed Effective Date
(Required)
MM slash DD slash YYYY
Experience Modification Factor
Is a Safety Program in operation at this time*
(Required)
No
Yes
Is this Applicant doing business as any other names or entities?
(Required)
No
Yes
List the other names/entities
(Required)
If there is more than one entity, are the financial records maintained separately?
(Required)
No
Yes
Are there any additional locations that are active under this current policy?
(Required)
No
Yes
Are there any additional companies covered under the current policy?*
(Required)
No
Yes
If business is a Sole Proprietorship/Partnership/LLC) Do the Owner/Partner(s) wish to be Included/Excluded?
Included
Excluded
(If business is a Corporation) Do the Owner/Partner(s) wish to be Included/Excluded?
Included
Excluded
Estimated Number of Employees
(Required)
Have deductibles been applied to losses in the past?
(Required)
No
Yes
Has the applicant ever been insured with the Kentucky AGC Self Insurers’ Fund?
(Required)
If yes, under what business/company name(s)?
No
Yes
Please provide more information
(Required)
Has the Applicant ever had a USL&H (Longshoreman) exposure?*
(Required)
No
Yes
Does the Applicant own, operate or lease an aircraft?*
(Required)
No
Yes
Is the Applicant related through common ownership or management to any other entity not listed on the ACORD or KY AGC/SIF applications?*
(Required)
No
Yes
List relations
(Required)
Is the Applicant seeking WC for any other entity, subsidiary or division not listed?*
(Required)
No
Yes
Please tell us what you are seeking
(Required)
Has the Applicant experienced a name change, ownership change or merger within the past five (5) years?*
(Required)
No
Yes
Enter the updated name, ownership change, or merger
(Required)
Are sub-contractors, casual laborers, contract laborers or 1099 employees used?*
(Required)
No
Yes
Does the Applicant ever hire employees, subcontractors or casual laborers from a state other than KY?*
(Required)
No
Yes
Do employees travel out of state?
(Required)
No
Yes
Does the Applicant have WC coverage for states other than KY?
(Required)
No
Yes
Payroll & Class Code Information
Class Code or Job Description
(Required)
#FT Employees
#PT Employees
Estimated Payroll per Class Code
Optional - Upload Supporting Documents
In order to provide a full quote, we will need the following, which you are welcome to upload here:
Completed ACORD Application
5 years of Loss Runs
2023 NCCI Experience Modification Worksheet
Most recent policy or audit
In order to bind, we will need the following, which are you are welcome to upload here:
Statement of Net Worth
Select PDF files:
Max. file size: 50 MB.
