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Mandatory Fields
EMPLOYER:
Coverage Effective Date:
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Today: 5/1/2025
Legal Status:
Individual
Partnership
Corporation
Association
Limited Partnership
Joint Venture
Multiple Status
Limited Liability Company (LLC)
Trust or Estate
Executor or Trustee
Limited Liability Partnership
Municipality
Other
Deductible Credit:
None
$500
$1,000
$2,000
$2,500
$5,000
Employers Liability:
9845 - Standard Limits
9803 - 100/100/1000
9807 - 500/500/500
9808 - 500/500/1000
9812 - 1000/1000/1000
Installment Basis:
Annual
Semiannual
Quarterly
Monthly
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
How many partners or members are included (1 to 999)?
Optional Field
Anniversary Rate Date:
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January
February
March
April
May
June
July
August
September
October
November
December
2015
2016
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2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
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2034
2035
>
Sun
Mon
Tue
Wed
Thu
Fri
Sat
27
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30
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Today: 5/1/2025
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):
Admiralty Employers Liability Limit:
None
10,000 Standard
50,000
100,000
Class Codes and Estimated Payroll
LOCATION #
SHIFT #
CLASS CODE
# OF EMP
ESTIMATED PAYROLL
USL&H
$
$
$
$
$
$
$
$
$
$
Add Class Codes