EFTA00308028.pdf

25 1 DOCUMENTS QUOTES Quotes You're one chat away from coverage Matthew Morris Hello! I'm Matthew, your personal agent and U.S. BASED LICENSED AGENT insurance expert. To ask a question or finalize your coverage, please send me a message or Direct line: give me a call at 973-939-2605 8.30am - 5pm I MONDAY - FRIDAY. We can also discuss 8.30am - 5pm I MONDAY - FRIDAY financing or payment options. EFTA00308028  Workers' Compensation AmTrust Insurance Company of Kansas, Inc. ■. Best Rating. N/A Quote #:1593659 Quote Coverage Details Bodily Injury by Accident, Each Accident $500,000 Bodily Injury Disease, Policy Limit $500,000 Bodily Injury Disease, Each Employee $500,000 These quotes are only estimates and are not a contract, binder or agreement to extend coverage.Your actual rates may be different depending on the underwriting criteria of each insurer and the specific characteristics of your business.Insurance taxes or other mandated premium surcharge may be billed in addition to the premium quotes.These preliminary quotes are available for your review for 30 days. $2,566 annually EFTA00308029  1184574 Neptune LLC ACC:7D 120 F. (Page 1 of 3) 3/12/2019 5:27.50 PM DATE eamtnemern ACORD FLORIDA WORKERS COMPENSATION APPLICATION 3/12/2019 PRODUCER PHONE COMPANY UNDERWRITER (NC No COY FAX AmTrust Insurance Company of Kansas, Inc. UM. NM 855457-0101 APPLICANT NAME •INCLUDE ALL suesioureas DBAW TO BE INCUJEIEDM COVERAGE. ALONG WITH THEM FEIN Automatic Data Processing Insurance Agency, Inc. Neptune LLC 1 ADP Blvd. PRIMAL PHYSICAL tOCATION AND ALL ;AWNED ENTRE-13 358 El Bello Way ADOITIONAL CHECK HERE IF LIST OF LOCATIONS ATTACHED HIS Roseland, NJ, 07068 Palm Beach FL 33480 uraNs€ 0: 1011912 YRS,. BUS I SIC CODE OTHER: coPP0nAnCer CODE: EVE COOS: 2 PARTNERSHIP STEICHAPTVI 13'CORP AGENCY CUSTOMER ID FEDERAL EMPLOYER ID NUMBER ! NCO E3 NURSER OTHER RATINGSURF.AU ID NUMBER 454093384 STATUS OF SUBMISSION BILLING I AUDIT INFORMATION 1 01107E I I ISSUE POLICY BILLING PLAN PAYMENT PLAN AUDIT a — —. Er AGENCY BILL DIRECT BILL ANNUAL SEMI-ANNUAL QUARTERLY J MEMFINANCED 1 OTHER % DOWN: _ AT EXPIRATION SERI-ANNUAL QUARTERLY H OTHER IIONTHLY LOCATIONS- `MSTilt $PHYSICALijear oN $S41120 I n ig(TIMPLOYEE n tliat ctA k;3 ece 41.13PITII:faint ° 24.1FTZe i ral ea 7/1 T ibt$$$ 40/4 $ S STREET, OM COUNTY. STATE. ZIP 000E 1 358 El Brio Way, Palm Beach, FL 33480 POLICY INFORMATION PROPOSED EFT DATE PROPOSED VIP DATE NORMAL ANNIVERSARY RATING DATE PARTICIPATING INTRO PLAN 3/23/2019 3/23/2020 NONPARTICIPATING PART 1• WORKERS PART 2 •EMPLOYER1LIABILITY PART 3 OTHER STATES INS DEDUCTIBLE OTHER COVERAGE COMPENSATION (Males) $ $ $ 500000.00 500000.00 500000.00 DISEASE • EACH ACCIDENT POLICY LINT DISEASE - EACH EMPLOYEE COINSURANCE LIMIT VII EH VOLUNTARY COMPENSAT DIVIDEND PLANT SAFETY GROUP ADDITIONAL COMPANY DIFORMATION RATING INFORMATION CHECK HERE IF LIST OF ADDITIONAL CLASS CODE COP- BOP ACTUAL [STRAYED LOC Ehl• REMUNERATION REMWIERATION ESTIMATED CLASS COOS PANT CATEGORIES. DUTIES. CLASSIFICATIONS PAST FOR NEAT HATE USE PLOYEES 12 MONTHS POLICY PERIOD ANNUAL PREMIUM I 0917 Residential Cleaning Services By C4 3 3 777 23.31 SPECIFY ADDITIONAL COVERAGESI[NDORSEMENTS FACTOR FACTORED PREMIUM TOTAL $ $ $ EXPERIENCE MODIFICATION $ MCOIRED PREMIUM . $ PREMIUM DISCOUNT i EXPENSE CONSTANT N/A $ 200 TOTAL ESTIMATED ANNUAL PREMEAI $ 72.566.00 I MDMIUMPREMIUM eeP0ST $ PREMIUM $ ACORD 130 FL (201902) Page 1 of 3 01991-2015 ACORD CORPORATION. All rights reserved. EFTA00308030  1184574 Neptune LLC ACORD 13O FL (Page 2 of 3) 3/12/2O19 5:27:50 PM INDIVIDUALS INCLUDED! EXCLUDED PARMA& OEFICERS. OWNERS TO DE PICLUOLD OR !ECLIPSED. IRE•WMULATION 0 SE INCLL0t0 lilLar St MR CO RAI,.G INIORMAIION ECIKINF ATTACH LIST OF ADOMOMSNAVAPTLYES. It ASV PROVIDE COPIES a CLUSIORS. DISCLOSURES OF THE SOCIAL SECURITY NUMBERS IS VOLUNTARY AS AN ALTERNATIVE ATTACH A COPY OF EMPTIER. OR INGLES/0V FEAR FILED Wnii TIE STATE OF FLORIDA. TITLE / OWNR RIC / 0 NAME GATE OF BIRTH SOCIAL SECURITY I itEstaxictup cm, 1ft DUTIES Exc CLASS CODE REMUNERATION i Jeffrey Epstein Sole Propnolol E 8810 47700 1OO 2 3 PRIOR CARRIER INFORMATION / LOSS HISTORY PROVIDE INFORMATION FOR THE PASTS YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS I I LOSS RUN ATTAOEO YEAR CARRIER & POLICY NUMBER ACTUAUAUMTTOPREIMMI MOD I CLAMS AMOUNT PAID RESERVE CO Pa.It CO Pa. FI: OD. POT. N: CO: ROL I: CO POL A: NATURE OF BUSINESS! DESCRIPTION OF OPERATIONS ONE COMMENTS AND DESCRIPTIONS OF ALL BUSINESSES, OPERATIONS AND PRODUCTS (INCLUDING OTHER STATES): MANUFACTURING - RAW MATERIALS. PROCESSES, PRODUCT, EQUIPMENT; CONTRACTOR • TYPE OF WORK. SUB-CONTRACTS; MERCANTILE • MERCHANDISE, CUSTOMERS. DELIVERIES: SERVICE -TYPE. LOCATION; FARM • ACREAGE. ATONAL!. MACHINERY, SUB-CONTRACTS. F CONTRACTOR. PROVIDE LICENSE NUMBER. PROFESSIONAL EMPLOYER ORGANIZATION (PEO)I EMPLOYEE LEASING COMPANY It TALTORNOT EL.:LOY/JERI SERVICE household employees EMPLOYEES -ATTACH A LIST Of ADDITIONAL EMPLOYEE NAMES NAME CLASS CODE SOCIAL SECURITY I NAME CLASS CODE SOCIAL secultny a ATTACH THE LAST FOUR (4] EMPLOYEES QUARTERLY REPORTS OR RS FORM 941. PLEASE EXPLAIN IF THE EMPLOYERS QUARTERLY REPORTS OR 941 IS NOT AVAILABLE DISCLOSURE OF THE SOCIAL SECURITY NUMBERS IS VOLUNTARY. AS AN ALTERNATIVE. THE LATEST EMPLOYERS QUARTERLY REPORT WITH CLASS CODES ADDED CAN BE USED *I LIEU OF A SEPARATE LISTING OF EMPLOYEE NAMES. SOCIAL SECURITY NUMBER AND CLASS CODE. ANY EMPLOYEES NOT ON THE EMPLOYERS QUARTERLY REPORT SHOULD BE SHOWN SEPARATELY. GENERAL INFORMATION °PLAIN ALL YES RESPONSES YES NO El:PLAIN ALL -TEST RESPONSES YES NO 1. DOES APPLICANT OW OPERATE OR LEASE AIRCRAFT/ WATERCRAFT/ d 18. ARE PHYSICALS REQUIRED AFTER OFFERS CIF EMPLOYMENT ARE WOE? 20O/HAVE PAST. PRESENT OR OISCONTIMIE0 OPERATIONS INVOLVE(D) 17. ANY OTHER INSURANCE WITH THIS INSURER? I STORING, TREATING. DISCHARGING. APPLYING. DISPOSING. OR TRANSPORTING OF HAZARCOUS MATERIAL? 0.9. WNW& Hostas. fuel talks, Mc) It ANY PRIOR COVERAGE DECLINED? CANCELLED? NONABIEWED OAK 3 PIMM? ,4/ 3. ANY WORK PERFORMED UNIERGROUND CR MOVE IS FEET/ It ARE EMPLOYEE HEALTH PLANS PRCANDED? A ANY WORK PERFORMED ON BARGES. VESSELS. DOCKS. MUGGE OVER WATER? 20.15 THERE MAJOR PITERCHANGE WTI ANYOTHER BUSPIESS I MISSIONUM S IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS? si 21. 00 YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? I S ARE SUBCONTRACTORS ARDORINDEPENDENT CONTRACTORS USED/ if 22. DO ANY EMPLOYEES PREDOMINANTLYIota AT HOME? 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.? 21 WHAT ARE YOUR ESTIMATED ANNUAL REVENUES?! 0 i 24. IS THERE ANY CURRENT OR ANTICIPATED DEBT FOE UNPAID PREMIUMS 16 A FORMAL SAFETY PROGRAM IN OPERATION? 4/ own TO ANY PREVICLIC WORAPRT COMPRMATION PRANITIFR? 9. ANY GREW TRANSPORTATION PROVIDED? 4/ CONTACT INFORMATION 10 ANY EMPLOYEES UNDER IS OR OVER SO YEARS OF AGE? IN. PHONE: 11. ANY PART TIME OR SEASONAL EMPLOYEES? SPECTIONNAME It IS THERE ANY VOLUNTEER OR DONATED LABOR? PHCRE ACCING 11 ANY EMPLOYEES WITH PHYSICAL HANDICAPS? RECCRO NAME: U. DO EMPLOYEES TRAVEL OUT OF STATE? GUYS Pine 11 ARE ADEETIC TEAMS SPONSORED? INFO NAME: REMARKS ACORD 130 FL (2015/02) Page 2 of 3 EFTA00308031  1184574 Neptune LW ACORD 130 FL (Page 3 of 3) 3/12/2019 517:50 PM ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE. DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE. OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE OR AS OTHERMSE PUNISHABLE AS PROVIDED UNDER THE LAW. I UNDERSTAND THAT AS THE EMPLOYER, I MUST UPDATE THE APPLICATION MONTHLY TO REFLECT ANY CHANGE IN THE REQUIRED APPLICATION INFORMATION; (THE FLORIDA WORKERS COMPENSATION CHANGE SHEET WILL BE USED FOR THIS PURPOSE) IF I FILE AN APPLICATION OR APPLICATION UPDATE CONTAINING FALSE. MISLEADING, OR INCOMPLETE INFORMATION WITH THE PURPOSE OF AVOIDING OR REDUCING THE AMOUNT OF PREMIUMS FOR WORKERS COMPENSATION COVERAGE IT IS A FELONY OF THE THIRD DEGREE OR AS OTHERWISE PUNISHABLE AS PROVIDED UNDER THE LAW. I SHALL SUBMIT TO THE CARRIER, A COPY OF THE EMPLOYERS QUARTERLY REPORT AND SELF-AUDITS SUPPORTED BY THE EMPLOYERS QUARTERLY REPORT, AS REQUIRED BY CHAPTER 443. AT THE END OF EACH QUARTER. IF I OMIT THE NAME OF AN EMPLOYEE FROM THIS EMPLOYERS QUARTERLY REPORT, FLORIDA STATUTES STATE THAT I WILL REMAIN LIABLE AND WILL REIMBURSE THE CARRIER FOR ANY WORKERS COMPENSATION BENEFITS PAID TO THIS OMITTED EMPLOYEE; I AGREE TO MAKE AVAILABLE, ALL RECORDS NECESSARY FOR THE PAYROLL VERIFICATION AUDIT AND PERMIT THE AUDITOR TO MAKE A PHYSICAL INSPECTION OF OUR OPERATIONS. I UNDERSTAND FAILURE TO DO THIS SHALL RESULT IN A $500 PAYMENT TO THE CARRIER TO DEFRAY THE COST OF THE AUDITS: THAT. IN ACCORDANCE WITH FLORIDA STATUTES 440.381(6). IF I (WE) UNDERSTATE OR CONCEAL PAYROLL. OR MISREPRESENT OR CONCEAL EMPLOYEE DUTIES SO AS TO AVOID PROPER CLASSIFICATION FOR PREMIUM CALCULATIONS, OR MISREPRESENT OR CONCEAL INFORMATION PERTINENT TO THE COMPUTATION AND APPLICATION OF AN EXPERIENCE RATING MODIFICATION FACTOR, I (WE) SHALL PAY A PENALTY OF TEN (10) TIMES THE AMOUNT OF THE DIFFERENCE IN PREMUM PAID AND THE AMOUNT I (WE) SHOULD HAVE PAID, AND REASONABLE ATTORNEY'S FEES. FORMER NAMES AND OWNERS FOR THE LAST 5 YEARS. LIST THE CURRENT BUSINESS NAME AND ANY FORMER NAMES OR PREDECESSOR COMPANIES FOR ALL COMPANIES TO BE COVERED BY THE POLICY. INCLUDE THE FEIN FOR EACH COMPANY. FOR EACH COVERED COMPANY. LIST ANY CURRENT OWNER WHO HAS MORE THAN 5% OWNERSHIP INTEREST. FOR EACH COVERED COMPANY OR PREDECESSOR COMPANY. LIST ANY OWNER WHO HAD MORE THAN 5% OWNERSHIP INTEREST IN THE LAST 5 YEARS. OWNERSHP I COMBINABILITY DOES THIS BUSINESS OR ANY OF THE OWNERS OF THIS BUSINESS, EITHER INDIVIDUALLY OR IN COMBINATION WITH OTHER OWNERS OF THIS BUSINESS. OWN MORE THAN 50% OF ANY OTHER BUSINESS, WHICH OPERATED AT ANY TIME DURING THE FIVE YEARS PRIOR TO THIS APPLICATION? O YES O NO OR, DOES THIS BUSINESS OWN A MAJORITY INTEREST IN ANOTHER ENTITY. WHICH IN TURN OWNS A MAJORITY INTEREST IN ANY ENTITY THAT OPERATED AT ANY TIME IN THE FIVE YEARS PRIOR TO THIS APPLICATION? ❑ YES ❑ NO IF THE ANSWER TO EITHER OF THE ABOVE QUESTIONS IS YES. COMPLETE THE FOLLOWING SUPPLEMENTAL OWNERSHP A COMBINABILITY QUESTIONS: I. IDENTIFY BY NAME. ADDRESS, AND FEIN EACH BUSINESS WHICH IS RELATED BY COMMON OWNERSHIP TO THE APPUCANT BUSINESS. 2. SET FORTH THE DATES EACH BUSINESS WAS IN OPERATION. THE INSURANCE COMPANY THAT PROVIDED WORKERS' COMPENSATION INSURANCE, THE POLICY NUMBER AND ME EXPERIENCE MODIFICATION FACTOR APPLIED TO EACH SUCH POLICY. 3. IF THE POLICY WAS WRITTEN WITHOUT AN EXPERIENCE MODIFICATION FACTOR, PLEASE STATE. THE APPLICANT HEREBY AUTHORIZES AND REQUESTS EACH RATING ORGANIZATION WITH EXPERIENCE RATING INFORMATION RELATED TO THE APPLICANT AND THE BUSINESS SET FORTH ABOVE TO RELEASE SUCH INFORMATION TO THE INSURER. FWCJUA. OR OTHER RATING ORGANIZATION SO THAT THE CORRECT EXPERIENCE MODIFICATION FACTOR CAN BE DETERMINED. I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND AS AGENT I PRODUCER. I HEREBY ATTEST THAT I HAVE GIVEN THE PERSONALLY SWEAR THAT THE INFORMATION CONTAINED IN THE APPLICANT/SIGNATORY THE OPPORTUNITY TO READ THE APPLICATION AND I APPLICATION IS ACCURATE, THAT I. AS AN OWNER/OFFICER, AM FULLY HAVE EXPLAINED ANY AND ALL QUESTIONS REGARDING THE APPLICATION. I AUTHORIZED TO SIGN THIS APPLICATION ON BEHALF OF THE APPLICANT ALSO ATTEST THAT I HAVE EXPLAINED TO THE EMPLOYER OR OFFICER THE AND TO BIND THE APPLICANT. CLASSIFICATION COOES THAT ARE USED FOR PREMUM CALCULATIONS PURSUANT TO SECTION 440.381 (2), FLORIDA STATUTES. OWNERI DATE PRODUCERS SIGNATURE DATE 08421(9 NAME NOTARY P DATE NOTARY PUBLIC SIGNATURE DATE ACORD 130 FL (2015/02) Page 3 of 3 EFTA00308032