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HOW TO APPLY FOR WORKERS' COMPENSATION INSURANCE

THROUGH KANSAS TRUCKERS RISK MANAGEMENT GROUP

If you would like to receive the advantages of self–insurance through the Kansas Truckers Risk Management Group, please provide Cowell Insurance Solutions with the following application material.

• Completed Acord Application

• Five year loss run (Past four years plus current)

• Current NCCI Experience Mod Worksheet

• Prior Years NCCI Experience Mod Worksheets

Please remit the above information to:

Cowell Insurance Solutions

Lance Cowell

lcowell@cisinsurancesolutions.com

Also provide a copy of your current NCCI Experience Modification Worksheet, if available, or complete the Authorization Letter (to be submitted on your letterhead).