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 ReleaseThis 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.
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 RequestA 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.
C105.2A 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.
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.
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A division of Safehold Special Risk, Inc.