Maverick General Agency, Inc.
INSURANCE APPLICATION
Application for Nonsubscribers Indemnity Policy with Maverick General Agency, Inc.

 
For coverage to be effective, you must include the following:
  • Completed application
  • 4 year loss history

Application Date: 

Proposed Effective Date: 

Once you have filled out the application you can click the "Confirm and Review Button" below; once you have reviewed your information you can submit this application instantly or you can print the application and mail or fax it to:
Maverick General Agency, Inc
PO Box 832474
Richardson, TX 75083-2474
Fax 877-437-1712 • Phone 877-434-1711 ext. 1

Subject to Underwriting.
Applicant Information
Name
Fed. Tax ID#
Mailing Address
City
State
Zip
Physical Address
City
State
Zip
Applicant's Business
Telephone #
Fax #
* Email
Contact Name
Business Structure
Years in Business
Date the Applicant has or will reject the WC Act
Effective Date
 
Agents Information
Agency
Agent e-mail
Producer
Producer e-mail
Street
City
State
Zip
Maverick Agency Number
Telephone #
Fax #
   
   
   
   
    Nature and Description of Operations 
Location Information:
Location # Street City State Zip Code Number of Employees Tallest Building Fire Protected?
 1 Yes No
 2 Yes No
 3 Yes No
Current Voluntary Benefit Plan (ERISA Plan) Information: Thes limits are not necessarily policy limits but are limits contained in the voluntary benefit ERISA plan.
Maximum amount per employee for all scheduled benefits. $
ERISA Plan sublimit for medical expneses. $
ERISA Plan sublimit for Accidental Death benefits. $
ERISA Plan sublimit for Weekly Income Indemnity (per week). $
ERISA Plan sublimit for Weekly Income Indemnity (weeks). #
ERISA Plan sublimit for Weekly Income Indemnity (salary). %
Does the plan provide for binding arbitration? Yes No
Does the plan provide for designated medical provider? Yes No
Is there a provision for reducing employee benefits proportionally to limit the recovery of benefits to the maximum insurance available? Yes No
Has the plan changed in the last three years? Yes No
If so, How?  Give details in the space below.
Details on plan changes: 
Prior Coverage Information
Omit if WC. * Current Period One Year Prior 2nd Year Prior 3rd Year Prior
Carrier
Per employee limit * $ $ $ $
Per occurance limit * $ $ $ $
Aggregate limit * $ $ $ $
Self insured retention
per employee $ $ $ $
or
per occurance $ $ $ $
payroll/employees $/ $/ $/ $/
Annual premium
General Information
Have you filed for bankruptcy in the last 5 years? Yes No
Do you have any employees subject to the USLH Act, the Jones Act or FELA? Yes No
Do you own, lease, or charter any watercraft or aircraft? Yes No
Do you provide transportation for employees to or from the workplace? Yes No
Do you use any subcontracted, temporary, leased, volunteer or donated employees? Yes No
Is there is any exposure to chemicals, drugs, pharmaceuticals or nuclear material? Yes No
Do you use/handle any fuels, explosives, asbestos or hazardous materials? Yes No
Use this space for details
Specific Information
Do you required employees to drive their own vehicles for your business? Yes No
     How many?
Number of employees who drive or who are a passenger of a company owned vehicle?
Number and type of vehicles owned or operated?   
Maximum height exposure (ft.)?   
Maximum weight of material handling (lbs.)?   
Number of employees who operate a forklift?   
Safety Plan Information
Do you have an employee safety program? Yes No Has your ERISA plan been distributed? Yes No
Do you have an alcohol/drug testing program? Yes No Do you investigate accidents? Yes No
Do you have a safety director? Yes No Have you had any OSHA violations in the last 5 years? Yes No
Details 
Rating Information (annual)
Classification WC Code # PT Employees # FT Employees Payroll
TOTALS
Executive officers are covered unless excluded by endorsement. Payroll for executive officers is limited to $62,400.
Name of executive officers to be excluded: 1.  2.  3. 
Loss Information - Valued as of (first $ losses per period)
Loss Period Beginning Date Medical Incurred Indemnity Incurred Total Incurred Total Paid No. of claims open No. of claims closed Annual Payroll or # of Employees Insurance Carrier
Current
Prior 1
Prior 2
Prior 3
Prior 4

Please provide details on each loss exceeding $50,000 on a separate sheet of paper.  Details should include the date, description and amount
Proposed Limits
Limit of Indemnity                                  Per person $                   Per occurrence $       Policy Aggregate $
Self Insured Retention                  Per occurrence $ (applies per occurrence for bodily injury and per emp. for OD and CT)
Accidental Death Benefit:                                          $ Disability Income Benefit: $                  per week for weeks
other requests