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EMPLOYER:  
Coverage Effective Date:
 
Legal Status:
Deductible Credit: Employers Liability:
 
Installment Basis: Is the premium being financed? no  yes 
Is the sole proprietor's wage included? no  yes  Are the partners' or members' wages included? no  yes 
Anniversary Rate Date:
Waiver of Our Rights Charge:
Experience/Merit Rating Factor(x.xx): ARAP Factor(x.xx):
MA Construction Credit Factor(xx): Former Self-Insurers Charge(whole dollar):
QLMP Credit(xx.xx): If Admiralty Coverage or FELA, are increased limits being requested?
 


LOCATION #
SHIFT #
CLASS CODE
# OF EMP
PAYROLL
USL&H