1Business Information

2Coverage

3EMOD

4Prior Coverage

5Estimated Premium

6Submit Application

Business Information

Do you have a Employer Identification Number (EIN)? *

An EIN is a federal tax ID number from the IRS for businesses, tax-exempt organizations and other entities.

What is your EIN? *

Enter your Employer Identification Number. Do NOT include dashes or any other characters.

What is your Social Security Number (SSN)? *

If you do not have an EIN from the IRS, enter your Social Security Number (SSN). Do NOT include dashes or any other characters.

Business Name *

Enter your legal business name in this box.

DBA

DBA stands for Doing Business As. If you operate using a different business name than your legal business name (like a brand name, assumed name, fictitious business name, or trade name), enter it in this box.

Entity Type *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Enter the mailing/billing address. This may be an out-of-state address or a different Kentucky address from the physical location.

Are the mailing address and physical address (Risk Location) the same?

Risk Location *

Address Line 1

Address Line 2

City

State

Zip Code

This MUST be a Kentucky address. Risk Locations are any workplaces or job sites where your business operates and employees perform work. Include addresses or descriptions of these locations to ensure they are covered under the workers' compensation policy.

Are there multiple Risk Locations? *

Addresses for Additional Risk Locations *

Provide all the address information (address, city, state, zip) for additional risk locations.

Coverage

Requested Effective Date *

Employer Liability Limits *

The basic employer liability limit is $100,000 per accident, $500,000 per policy, and $100,000 per employee and helps cover legal expenses if an employer is sued for punitive damages for a work-related injury or illness.

Will any owners/officers of the organization be included in this coverage? *

EMOD

An experience modifier (sometimes called an experience modification factor or EMOD) is calculated by the National Council on Compensation Insurance (NCCI) according to the terms of the Experience Rating Plan Manual. An EMOD is an adjustment of an employer's premium for workers' compensation coverage based on the losses the insurer has experienced for that employer.

Typically, three full years of payroll and loss information is used in the calculation and produces a factor that is applied for one year. The plan is mandatory for all employers who qualify (in general, and average of $5,500 in premium for three years).

EMOD

If you know your current EMOD, enter it here. If not, you may leave this field blank and continue.

Prior Coverage

How many years has this entity been in business? *

Have you had prior workers' compensation insurance coverage? *

Prior Carrier *

Enter the name of the prior insurance company.

How many claims have occurred in the last five years? *

If you had previous coverage, a loss run is required for a complete submission. Provide 3 years of loss runs valued in the last 30 days. This could include loss runs from multiple carriers. If you are unable to upload below, please fax 859-425-7828.

Additional Details

Describe the Business *

Provide a detailed description of your business operations. Include specific information about work being done in Kentucky.

Number of Kentucky Employees *

Estimated Annual Payroll for Kentucky Employees *

Is this business tax exempt? *

Tax-exempt status means that an organization is exempt from paying federal corporate income tax. Examples of such organizations are charities with 501(c)(3) status from the Internal Revenue Service (IRS).

Are there any additional Named Insureds? *

Additional Named Insureds are individuals or entities, beyond the primary policyholder, who are explicitly covered under the workers' compensation policy. This may include business partners, subsidiaries, or other related parties requiring coverage. List their full legal names here.

Additional Named Insureds *

List all additional named insureds in this box.

Is coverage needed in states other than Kentucky? *

Contact Name *

KEMI will follow up with this individual regarding this application.

Phone *

Email *

Confirm Email

A confirmation email will be sent to this address. This contact email will also receive information about registering for our online services if coverage is bound.

Website

Upload Prior Carrier Audits, Loss Runs, Tax Forms, or Other Relevant Information

Click or drag files to this area to upload. You can upload up to 10 files.

Upload any documents that may assist KEMI in the review process for this applicant. Examples may include prior carrier audits, tax forms, and any other relevant documentation. You may add multiple files below. If you are unable to upload, please fax to 859-425-7828.

Comments:

Enter any questions or comments regarding this application.

Acknowledgment Required *

Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. The undersigned is an authorized representative of the applicant and represents that reasonable inquiry has been made to obtain the answers to questions on this application. He/She represents that the answers are true, correct and complete to the best of his/her knowledge.

Signature *

Clear Signature

Direct Business Questionnaire

Business Information

Coverage

EMOD

Prior Coverage

Additional Details

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