APPLICATION FOR INSURANCE QUOTATION - …

1 commonwealth of puerto rico STATE INSURANCE FUND CORPORATION APPLICATION FOR INSURANCE QUOTATION SECTION I : GENERAL INFORMATION 1. Name of Employer: 2. Name of Spouse: (if individual) 3. Employer or Individual Social Security Number: 4. Mailing Address PO Box or Street, Residencial Development or Neighborhood: 5. Residencial Address or Main Office: 6. Residencial Telephone: Business Telephone: Fax: 7. Do you have or had carried a policy with our Corporation: Yes No Policy Num.: 8. Type of Employer: 01 Individual 06 Trustee 11 Club 16 Non Register Partn. 02 Partnership 07 Executor 12 State Gov. 17 Public Corp. 03 Corporation 08 Sucession 13 Special Partnership 18 Other: 04 Cooperative 09 Municipality 14 Foreign Corp.

2 05 Association 10 Church 15 Municipal Corp. Resident Agent: Telephone: Fax: Mailing Address: Residencial Address: 9. Do you work with Accounting Financial Statements? Yes No E-Mail: 10. Activities: Detail all the Activities Num. Employees Estimate Payroll by Activity Starting Date of Operation (Month-Day-Year) Estimate Term Operation (in months) Estimate Ending Date of Operation (Month-Day-Year) For Temporary Policies: Available Budget ARPE: Case Number in ARPE: Year: Contract: Total Amount of Contract: LOCATIONS TO BE INSURED SECTION II : LOCATIONS Name of Business: Physical Address: City: Zip Code: State: Name of Business: Physical Address: City: Zip Code: State: Name of Business: Physical Address: City: Zip Code: State: If you have more than tree (3) Locations, use a separate sheet.

3 Furnish the following information with regard to corporation s executive officers, industrial partners or individual business administrators. (if individual) ONLY FOR PERMANENT POLICIES Name Title Physical Address Salary Res. Telephone I certify that the information offered is accurate and correct, therefore, I am requesting an INSURANCE policy to comply with the workers compensation Law. Name and Title of Employer or Authorized Representative Signature of Employer or Representative You should include an identification number (photocopy of driver s license) from the person who is delivering the document to the Corporation. Identification Number Type FOR SIFC USE Coverage: The policy will cover from at and will expire on (Month-Day-Year) subject to conditions and limitations under the Law and Regulations of the State (Month-Day-Year) INSURANCE Fund Corporation.

4 (Month-Day-Year) Name and Signature of the INSURANCE Investigator Officer Name and Signature Chief Underwriting Section LOCATIONS TO BE INSURED ADITIONAL SHEET Name of Business: Physical Address: City: Zip Code: State: Name of Business: Physical Address: City: Zip Code: State: Name of Business: Physical Address: City: Zip Code: State: Name of Business: Physical Address: City: Zip Code: State: Name of Business: Physical Address: City: Zip Code: State: Name of Business: Physical Address: City: Zip Code: State.