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First Name *

Last Name *

Email *

Phone Number *

Cell Phone

Fax Number

Business Name

Agent Number

Policy Number

Effective Date

Business Address

Address

Suite #

City

State

Zip

Mailing Address

Business Address and Mailing Address are the same.

Address

Suite #

City

State

Zip

DECLARATION OF APPLICATION FOR SAFETY GROUP MEMBERSHIP

The Applicant is a member of the Sentinel Restaurant Association. The Applicant agrees to promptly pay all Group Workers' Compensation premiums and deposits when billed and due. The Applicant understands and agrees that upon failure to pay any outstanding financial obligations due on his account to the Insurer, or to maintain Association membership, the Applicant will immediately cease to be a Group Member. The Applicant gives the Group Secretary power of attorney to obtain and use, in the interests of the Group or the individual Member, any information held by the Insurer relating to claims, experience rating, loss prevention services or other information which may be the subject of Group research and inquiry.

The Applicant understands that:

Individual Workers' Compensation policies are considered for issuance to Association members in accordance with applicable rules and regulations, as determined by the insurance carrier.
The insurance carrier does not intend to declare dividends respecting the subject Workers' Compensation policies.
Active participation in the safety activities of the Group is a requirement for continued membership in the Group.

Dates and amounts of distribution may vary according to the policies of the Insurer or Trustees.

I agree to all the term & conditions in the Declaration.