AgriTrust of Georgia
Workers' Compensation Self-Insured Trust Fund
"Quick Application"

Please complete the following application. We will contact you if additional information is needed to complete the quote of insurance premiums for workers' compensation insurance coverage.

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Applicant Information

Business Applicant Name:

Mailing Address:   

City, State, Zip:   

Phone #:   

Company Contact:      

Company Contact E-mail Address:  

Company FEIN#:   

Type of Business:    Sole Proprietorship Partnership Corporation Limited Liability Company Other

Description of Operation:

Proposed Effective Date of Coverage:   

Payroll Information

Enter the various workers' compensation class codes and estimated payroll for that classification: 
(Example: 8810 Clerical = $125,000)
  Class Code Annual Payroll per Class 1. 2. 3. 4. 5. 6. 7. 8.

Loss Information

No workers' compensation losses to date

Workers' comp. losses to date include:
(Example: 03/15/98, Head Trauma, $1,000)
Provide accident date, brief description, and amount of claim 1. 2. 3. 4. 5. 6.

Premium Payment Method Preferred:
  25% down payment with 3 installments Monthly reporting with 25% deposit

Drug Testing Program Credit:
1% - Post accident and reasonable suspicion drug/alcohol testing. 3% - Pre-employment, post accident and reasonable suspicion drug/alcohol testing. 5% - Annual testing of all employees. 7.5% - Certificate from the Georgia Chamber of Commerce "Drugs Don't Work" Program

Deductible Plan Credit:    No per claim deductible = 0% discount $100 per claim deductible = 0.6% discount $200 per claim deductible = 1.0% discount $300 per claim deductible = 1.4% discount $400 per claim deductible = 1.7% discount $500 per claim deductible = 2.1% discount $1,000 per claim deductible = 3.4% discount $1,500 per claim deductible = 4.5% discount $2,000 per claim deductible = 5.4% discount $2,500 per claim deductible = 6.3% discount

Insurance Agent Information

Do you plan to have this coverage obtained through an insurance agent?Yes      No

If yes, please provide the following information:
Agency: Address: City, State, Zip: Phone #: Agency Contact:

Thank you!  Please click the submit button and we will follow-up with you as soon as possible.

Please note that in order to bind coverage you must be a member of the Georgia Agribusiness Council and additional information may be necessary before a quote can be provided.

Thanks again!  We look forward to talking with you soon.

Back to AgriTrust of Georgia

Georgia Agribusiness Council, Inc.    
Post Office Box 119     Commerce, GA 30529
7o6/336-6830      800-726-2474      (FAX)706/336-6898