Instructions for Applications

Workers Compensation:
Complete an Acord 130 (www.acord.org/webfiles/forms/static/130.pdf) and an American Mining WC Supplement. This supplement includes an employee census form that must be completed prior to quoting a risk with "Black Lung" exposure. 
(WC Supplement, including Employee Census: Excel format or PDF format).  Please follow the included instructions.

Commercial General Liability & Pollution Liability:
Complete an Acord 126 Commercial General Liability Section. www.acord.org/webfiles/forms/static/126.pdf),
an Acord 125 Applicant Information Section (www.acord.org/webfiles/forms/static/125.pdf) and
AMIC's Mine Liability Supplement (Word format or PDF format).

Business Auto:
Complete an Acord 127 Business Auto Section (www.acord.org/webfiles/forms/127.pdf ) and an Acord 125 Applicant Information Section (www.acord.org/webfiles/forms/static/125.pdf).

Coal Truckers Business Auto: (Available in PA & VA only)
Complete an Acord 127 Business Auto Section (www.acord.org/webfiles/forms/127.pdf ), an Acord 125 Applicant Information Section (www.acord.org/webfiles/forms/static/125.pdf)
and AMIC's Coal Truckers Business Auto Supplement
(Word format or PDF format).

Commercial Umbrella:
Complete an Acord 131 Umbrella / Excess Section (www.acord.org/webfiles/forms/static/131.pdf) and an Acord 125 Applicant Information Section (/www.acord.org/webfiles/forms/static/125.pdf). 
Note that we must write the General Liability before writing the Umbrella.

Please provide five (5) years company loss runs for all lines submitted.  If these are not available, please explain.  While we will endeavor to quote as soon as possible, please allow at least thirty (30) days to underwrite an account.

Thank You for your Submission

Frequently Used Forms

Pennsylvania Selection of First Party Benefits (PDF format)

Applications are provided in Adobe Acrobat format (some are also provided in Microsoft Word and Excel format). Adobe Acrobat Reader is required to view and print acrobat (PDF) files. Many of the PDF files provided are fillable electronically. If you don't already have Acrobat Reader, you may download it for free from www.Adobe.com or click on the icon below.