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FORMS


GENERAL

South Carolina Exclusion Form

ContactFlorencia Bair for a brokerage agreement. This document must be completed, submitted and approved before a broker can do business with us. It sets forth the terms and conditions under which the broker and Agency Resources agree to do business.

Lost Policy Release
This form is used to request cancellation of a policy. The form must be completed, signed, and have a detailed reason for cancellation indicated. For example, if coverage has been replaced, the form must include the replacing carrier's name, policy number, and effective date.

WORKERS' COMPENSATION

New York Revocation of Election of a Corporation Form

Notice of Election of Coverage

Revocation of Election of Coverage

Notice of Election to be Exempt

Notice of Revocation of Election to be Exempt

Instructions for Completing Construction Industry Application For Exemption

Instructions for Completing Non-Construction Industry Corporate Officer Application for Exemption

Application for Drug-Free Workplace Premium Credit Program

Certification of Employer Workplace Safety Program Premium Credit

ERM-14 
This form is used to report any changes to an insured business that may or may not affect the pricing of a workers' compensation policy. A policyholder is required to report a name change, a change of ownership, a merger or consolidation, or any other significant change to the carrier within 90 days of a change. The completed form should be submitted to Agency Resources.

Waiver of Subrogation Request
A waiver of subrogation is a condition of a contract or policy in which the insured relinquishes in writing any right to recover damages against another party. Its purpose is to minimize lawsuits and claims.

C105.2
A C105.2 is a certificate of insurance that serves as proof of insurance. If issued from our office, it must have the signature of our underwriting manager to be valid.

OWNER OR OFFICER STATE ELECTION/REJECTION OF COVERAGE FORMS

If an officer, member, partner, or sole proprietor is listed on the back of the Acord 130 as included or excluded, the appropriate form for the state in which the insured is domiciled is required at the time of binding.

Connecticut Officer Exclusion

Florida Officer Exclusion

Illinois Election/Rejection Form

Massachusetts Officer Exclusion

Maryland Officer Exclusion

New Jersey Office Exclusion

New York Notice of Election

New York Officer Exclusion

Pennsylvania Officer Exclusion

Products and services are offered through Agency Resources, a division of Safehold Special Risk, Inc., dba Safehold Special Risk & Insurance Services, Inc. in California. Safehold is a division of Wells Fargo Insurance and a non-bank insurance agency affiliate of Wells Fargo & Company. Coverage is provided by unaffiliated insurance companies.

By clicking on links to third-party websites, you will leave the Agency Resources Web site and enter a privately owned Web site that is not affiliated with Agency Resources or its affiliates. The information and opinions found on third-party Web sites have not been verified by our Firm, nor do we make any representations as to its accuracy and completeness. By linking to this Web site, Agency Resources is not endorsing the third-party's products and services, or its privacy and security policies, which may differ from Agency Resources and/or its affiliates. We recommend that you review the third-party's policies and terms and conditions to fully understand what information may be collected and maintained as a result of your visit to this Web site.

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