Join The Fund - Kentucky AGC Self Insurers' Fund

Legal Name of Business(Required)

FEIN(Required)

Contact Name(Required)

Contact E-mail Address

Payroll & Premium Contact(Required)

Claims Contact(Required)

Safety Contact(Required)

Date Business Started(Required)

Years of Operation-Related Experience(Required)

Confirmed membership with the following association(Required)

Local Chapter (if applicable)

Description of Operations*(Required)

Current Agent/Broker(Required)

Insurance Agency(Required)

Agent E-mail Address*(Required)

Current/Previous Insurer Name(Required)

Annual Premium

Policy Period Effective Date(Required)

Policy Period Expiration Date(Required)

Proposed Effective Date(Required)

Experience Modification Factor

List the other names/entities(Required)

Estimated Number of Employees(Required)

Please provide more information(Required)

List relations(Required)

Please tell us what you are seeking(Required)

Enter the updated name, ownership change, or merger(Required)

Class Code or Job Description(Required)

#FT Employees

#PT Employees

Estimated Payroll per Class Code

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.