MMTA: WCT Prospective Member

WCT Prospective Member

We would be happy to send you more information about our self-insured workers' compensation program. In order to better serve you, please answer a few questions about your organization - results will be held strictly confidential.

For a direct link to the Trust's website, visit www.workerscompme.com

Company Information

* are required

Company Name*
Address*
City*
State*
Zip Code*
Contact Name*
Contact Phone Number*
Contact E-mail*
Number of Employees*
Are You a Member of the Maine Motor Transport Association?*	Yes No
Current Maine Workers' Compensation Company*
Current Experience Modification Factor*
Does your company have modified duty, safety and disciplinary policies and procedures?*	Yes No

Estimated Yearly Payroll by NCCI Classcode

* are required

NCCI Classcode 1:*		Estimated Yearly Payroll*
NCCI Classcode 2:		Estimated Yearly Payroll
NCCI Classcode 3:		Estimated Yearly Payroll
NCCI Classcode 4:		Estimated Yearly Payroll
NCCI Classcode 5:		Estimated Yearly Payroll
NCCI Classcode 6:		Estimated Yearly Payroll
NCCI Classcode 7:		Estimated Yearly Payroll
Comments:

Financials

* are required

Does your company have either Audited or Reviewed financial statements?*

Yes
No

PLEASE NOTE:

Maine Bureau of Insurance regulations will not allow us to consider internally-developed financial statements due to joint and several liability concerns. Please consult your accountant if you are not sure if your statements comply with the Audited or Reviewed requirement.

Validation
Please type in the letters/numbers in the validation box.