Renew

Business Name *

Workers Comp Policy Number *

Email address: *

Comments

Website:

Phone *

Applicant is:

Corporation

Non-Profit

Sole Proprietorship

Other

Mailing Address: *

Contact Name *

Declaration of Applicant For Group Membership

The applicant is a member of the Association of All Great Retailers. The Applicant agrees to promptly pay all Group Workers' Compensation premium and deposits when billed and due. The applicant understands and agrees that upon failure to pay any outstanding financial obligations due on this account to the insurer,Farmers Insurance Group, or to maintain Association membership, the Applicant will immediately cease to be a Group Member. The applicant gives the Group Secretary power of attorney to obtain and use, in the interests or the Group of the individual Member, any information held by the insurer relating to claims, experience rating, loss prevention services or other information which may be the subject of Group research and inquiry.

Association of All Great Retailers RENEWAL APPLICATION

(Group #75 to 75-13)