• Fully completed Acord 130 or online application via kemi.com.
• Three years of currently valued loss runs from the previous carrier if prior coverage existed.
• Last three completed payroll audits if previously insured by a self-insured group fund.
• Corporations and limited liability companies (LLC) must be active and in good standing with the Kentucky Secretary of State.
• Federal identification numbers (FEIN) are required for businesses operating as partnerships, corporations, and LLCs.

For coal mine submissions, the forms listed below are also required. Forms require Adobe Acrobat Reader and will open in a separate window. Please have pop-up blockers disabled.

• Coal Mine Supplemental Questionnaire
• Coal Mine Census

In the event multiple submissions are received, the agency submitting the first complete submission will be recognized as the agent of record (AOR).