[]
1 Step 1

United Caregivers Association
2775 Tapo Street #101
Simi Valley, CA 93068
www.unitedcaregivers.org
charley@bealsagency.com
PHONE: 805-379-2022
 

Enrollment Application

1. Full Name of Application
D.B.A.
2. The Applicant is:
3. Mailing AddressStreet Number
City
Zip Code
4. LocationLocation 1:
Location 2:
Location 3:
5. Agency
Producer
6. Policy Number
Effective Date



“UCGA Annual Membership dues are $50.00. Make check payable to United Caregivers Association.”

DECLARATIONS OF APPLICATION FOR UNITED CAREGIVERS ASSOCIATION

The applicant is a member of the United Caregivers Association. The applicant agrees to promptly pay all premiums and deposits when billed and due. The applicant understands and agrees that upon failure to pay any outstanding financial obligation due on his account to the insurer, or to maintain association membership, the Applicant will immediately cause to be a Group 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:

  1. Individual Worker’s Compensation policies are considered for insurance to Association members in accordance with applicable rules and regulations, as determined by the insurance carrier.
  2. The insurance carrier does not intend to declare dividends impacting the subject Workers Compensation policies.
  3. Active participation in the safety activities if the Group is a requirement for continued Membership in the Group.
Acknowledgement of the DeclarationApplicant Signature
DateToday's Date
Print Name
Title

 

 

Previous
Next