Entity Name *

Contact Name *

First

Last

Phone *

Email *

Website / URL

In which state is your entity registered? *

List all entity owners' names, dates of birth, social security numbers, if they wish to be included or excluded from coverage, and their job duties. *

This information is required.

Do you have an insurance agent? *

Yes
No

Have you had coverage in Kentucky or any other state? *

Yes
No

How did you hear about KEMI? *

Detailed description of overall operation of your business: *

Detailed description of work being performed in Kentucky: *

List of jobs in Kentucky: *

Number of your employees working in Kentucky: *

Estimated timeframe for completion of your work in Kentucky: *

Please explain any safety measures your organization currently has in place (you will be asked to upload documentation on the next screen): *

Kentucky: any Do

Who is requesting proof of insurance? *

Do you intend on hiring subcontract labor? *

Yes
No

Do you provide temporary labor services to other employers? *

Yes
No

Do you use any temporary labor services? *

Yes
No

Upload Supporting Documentation

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

Upload tax documents, prior loss runs, safety procedures, etc.

Additional comments:

Use this box to provide any additional comments or helpful information for us to consider while we review this questionnaire.

Direct Business Questionnaire

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