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Program Application |
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Acord Forms (125 and 127 at a minimum) |
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3-5 years of currently valued hard copy carrier loss runs |
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Driver Schedule to include Full Driver Name, DL # DL State, Date of Birth and Date of Hire |
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Include MVR's if available |
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Vehicle Schedule to include Year, Make Ambulance Mfr., Type (I,II or III), Original Cost New, Current Value and Lienholder information (for example-2003 Ford AEV Type II OCN $72,000/ACV $28,000 no lien) |
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If new or newer venture (less than 3 years in business), please also include resumes of the firm principals, a copy of their business plan and current financial statements. |
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For Workers' Compensation submissions, please provide the following items: ACORD WC application, THOMCO supplemental WC application, 3 years of currently valued hard copy carrier loss runs that include the current year and the current experience mod worksheet. This coverage is currently available in the following 36 states: AR, AZ, CA, CT, DE, FL, GA, IA, ID, IL, IN, KS, KY, LA, MD, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NY, OK, PA, RI, SD, TN, TX, UT, VA, VT and WI.
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Workers' Compensation Supplemental Application |
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Driver Change Form |
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Kent.Clements@thomcoins.com
