Personal Information (required) Applicant Name First Middle Last Applicant FEIN Applicant mailing address Street City StateSelect...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Coverage Information Number of Employees Full Time Part Time *Full Time = over 18 hours per week Effective Date of Policy Any employees under 16 or over 60 years of age?Yes No Any prior coverage declined/cancelled/non-renewed in the last three (3) years?Yes No Is the employee a family member residing in the home?Yes No Are employees U.S. Citizens or do they have the legal right to remain and work in the U.S.?Yes No Application submitted by Remarks With this transmission, Guardian Trac, LLC and Larkin Insurance Group, Inc agree to the following terms: Larkin Insurance Group will bind coverage with Accident Fund Insurance Company of America unless notified otherwise by Guardian Trac, LLC. Larkin Insurance Group agrees to notify Guardian Trac, LLC of any application unacceptable to Accident Fund. Coverage will be effective the date requested on the submission or up to ten (10) days prior of the receipt of the submission. Under no circumstances will coverage be bound retroactively more than ten (10) days prior to the date of receipt. All submission requests made after normal business hours will be deemed received at the start of the next business day. Guardian Trac, LLC confirms that they have a signed Power of Attorney with authorization to "sign on behalf of" on file for this client and will provide a copy of the POA at any time upon Larkin Insurance Group's request. Guardian Trac, LLC agrees to notify Larkin Insurance Group immediately of any changes necessary. Guardian Trac, LLC agrees to pay all premiums generated by coverage bound under the provisions of this agreement.