OtherName of EntityContact Name Contact Phone Number Contact Email Address Entity Typempany Website In what state is your entity registered Do you have an insurance agent YesIs your agent licensed ID: 877734
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1 Other KEMI Direct Business Questionnaire
Other KEMI Direct Business Questionnaire Name of Entity:___________________________________________ Contact Name: ___________________________________________ Contact Phone Number: ____________________________________ Contact Email Address: _____________________________________ Entity Type: mpany Website: _________________________________________ In what state is your entity registered: ___________________________ Do you have an insurance agent YesIs your agent licensed in Kentucky? Yes NoHave you had coverage in Kentucky or any other state? YesNo State of coverage:______________________________________ Name of carrier:________________________________________ III.Dates of coverage:______________________________________ De
2 tailed description of overall operations
tailed description of overall operations of your business:Detailed description of work being performedin KentuckyList of job locations in Kentucky: Number of employees working in Kentucky: _______________________ Estimated timeframe for completion of work in Kentucky: Who is requesting proof of insurance: ____________________________ Do you intend on hiring subcontract labor? YesPlease explain any safety measures currently in place, providing copies of any available writtendocumentation:Do you provide temporary labor services to other employers? YesDo you use any temporary labor services? YesAdditional comments:Click here for Underwriting FAQ’s. Return business questionnaire to KEMI Underwriting at KEMIdirect@kemi.com .