Scheers Specializing in Bonds Since 1963
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1. Name of Applicant: *
Address: *
City: *
State: *
Zip: *
Telephone: *
Fax:
Name of Applicants
Business:		 *
Web site, if any:
How long in business? *
Is Applicant a: * Corporation Partnership Sales Proprietor
Chartered under
the laws of the
State of:		 *
2. Is Applicant a:

Corporation Partnership Sales Proprietor

of a parent company?

If yes, please complete the following in reference to parent company:
Name:
Address:
City:
State:
Zip:
Parent Company Is a: Corporation Partnership Sales Proprietor
3. Aggregate Excess Insurance Carrier(s):
Current Annual Manual Premium:
Estimated Loss Fund:
Policy Period From: To
Aggregate Excess Limit of Liability:
4. Specific Excess Insurance Carrier(s):
Amount of Specific
Self-Insured Retention:
Specific Excess Limit of Liability:
5. Claim Administrator(s):
Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Is this firm responsible for Safety Engineering? Yes   No
If no, who:
6. How long has Applicant been Self-Insured? *
7. Total amount of security deposit required by Illinois Industrial Commission: *
8. Amount of Bond requested: *
If less than #7, how is the difference made up? Escrow    LOC    Bond    Other
9. Total outstanding Workers’ Compensation loss reserves (currently valued) for entire self-insured period: *
10. Is Applicant fully self-insured for any coverages such as product liability, malpractice, property, casualty, employee benefits, etc.?
* Yes   No
If yes, please list the type(s) of coverage:
11. Does Applicant have any locations with over 100 employees in Cook County, IL, or any other large Metropolitan area?
* Yes   No
If yes, please list the additional information:
Address of locations:
Maximum number of employees at any given shift, per location:
12.

Approximate percentage of operations located in Cook County, IL, or other large Metropolitan area:

* %

The applicant does or do hereby represent that the statements made in the foregoing interrogations are true.
Name of Applicant: *
Title: *
Date: *

Please send the following:

1. Last 3 years’ Certified Financial Statements, if available, or last 2 years Federal Tax Returns.

2. Last 3 years of Loss Runs (currently valued – no less than 3 months).

3. A copy of most recent Certificate of Excess Workers’ Compensation Insurance and evidence of terrorism coverage.

4. A copy of most recent Certificate of Property Insurance/Coverage, and evidence of terrorism coverage.

5. A copy of state’s approval for applicant to be self-insured.

6. A completed BRPS Agreement of Indemnity.

7. If applicable, information required per question #11 above.
 
 
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601 Oakmont Lane, Suite 400 • Westmont, IL 60559 • Phone 630.468.5600 • Toll Free 888.236.9514 • Fax 630.468.5697