*Company Name
*Business Address
*City *Zip Code
*Name of Contact
Mailing Address (If Different)
*City *Zip Code
*Phone:
( )   - Ext.
Fax Number
( )   -
*Email *Verify Email
Name of Officers/Partners
Contractor's License #
*Classification Code(s) (See Chart Below)
Number of Employees Years in Business
Worker's Comp Provider

Membership

Auxiliary Membership: Fees are $100.00 pr year. An Auxiliary Member shall not be entitled to vote, hold office in the Association, or have any other priviledges except as expressly determined by the Board of Directors. In order to be an Auxiliary Member you must
(1) Have a State Fund Workers Compensation Policy,
(2) Be a licensed contractor,
(3) Meet the criteria for our group program, which is a loss ratio of 50% for the two most recently completed policy years and an experience modification of 110% or less. (Exceptions are at the discretion of the State Fund), and
(4) A loss of your State Fund policy is grounds for non-renewal of your auxiliary membership; you may convert it to another class of membership.

MEMBERSHIPS ARE SUBJECT TO THE FOLLOWING TERMS AND CONDITIONS:
1. Membership shall be for one year.
2. This application is subject to the approval of the Membership Committee and the Board of Directors.

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