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Hotel and Motel Safety Association

Hotel Motel Safety Association USA, Inc.
1320 Flynn Rd., Suite 203, Camarillo, CA 93012
Phone (877) MY-SAUSA Fax (877) MY-SAUSA
www.safetyassociationusa.com

Company Name

DBA

Last Name

First Name

Phone

Fax

Business Type

	Corporation
	Partnership
	Sole Proprietor
	Other (Enter below)

Mailing Address

Physical Address

Association Dues

$250.00

Association annual nonrefundable membership dues are $250 which is due at the time the application is submitted. Agent will be invoiced for your annual membership dues upon your policy renewal. Please make check payable to Safety Association USA. Premium discount =5%. Class codes for this association are 9050 Hotels – All Employees.

Declaration of Application
Applicant hereby applies for membership in the Hotel Motel Safety Association (“Association”). Applicant agrees to timely pay all Group Workers’ Compensation premiums, deposits and membership fees when due. Applicant unde rstands and agrees that upon Applicant’s failure to pay any outstanding financial obligations due on his/her account to the in surer, premium discounts will be revoked and you will cease to be an Association member. Applicant gives the Association Power of Attorney to obtain and use, i n the interest of the Association, any information held by the Insurer relating to claims, expe rience rating, loss prevention ser vices or other information that may be the subjec t of Association research and inquiry. Applicant hereby agrees to follow and post a written (SB198) Wo rkplace Safety Program, prescribed by Cal-OSHA, including, but not limited to, holding quarterly safety meetings with all employees.