Get New Jersey Large Risk Large Deductible Program Notice Of Election

This guide provides a comprehensive overview of the New Jersey Large Risk Large Deductible Program Notice Of Election form. By following the steps in this guide, users will be able to efficiently and accurately complete the form online, ensuring compliance with the relevant requirements.

Follow the steps to fill out the form correctly and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by providing the name and address of the insured in the first field. Ensure to include all relevant information, as shorthand or abbreviations such as 'et al' are not acceptable.
3. Enter the policy number(s) in the designated field below the name and address.
4. Fill out the effective dates of the policy by stating both the effective start and end dates.
5. Indicate the total estimated New Jersey annual workers compensation standard premium in the specified field.
6. Provide the total estimated countrywide annual workers compensation standard premium in the following field, including the premium from the previous step.
7. Specify the deductible amount for each accident in the corresponding box.
8. Provide the deductible amount for each person or each occurrence in the next field.
9. Fill in the occurrence aggregate limit in the respective field.
10. Indicate the countrywide aggregate limit in the next section.
11. State whether allocated loss adjustment expenses will be included or excluded.
12. Select whether the deductible premium will or will not be subject to retrospective adjustment.
13. Complete the total New Jersey deductible premium by entering the relevant dollar amount.
14. Enter the total countrywide deductible premium in the designated field.
15. Specify any exceptions regarding the entire New Jersey operations of the insured.
16. Mention the form of security and provide the name and address of the bank.
17. Identify the insurance carrier by name, and ensure that it is signed by an authorized representative with their title and address.
18. The form must also be signed by the insured, indicating the title and address of the signatory.
19. Once all sections are completed, review the information for accuracy before finalizing your submission. Save changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth filing process.