Workers’ Compensation


    Named Insured (required)

    Email Address (required)

    Mailing Address:

    Phone(required)

    Fax

    Entity

    Number of years in business

    Federal ID Number

    Current Experience Modification

    Current Effective Date:

    Loc#   Address of Permanent Locations
    (workplaces-permanent offices-not a temporary work site)
      # of Full
    Time Employees
      # of Part
    Time Employees
    1               
    2               
    3            
    4            
    5            
    6            


    Rating Information

    Location   Class Code   Duties   Estimated Annual
    Remuneration*
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  

    *Remuneration to include, if applicable, market value of lodging.



    IF ENTITY IS A CORPORATION / PARTNERSHIP / LLC LIST INDIVIDUALS TO BE INCLUDED / EXCLUDED
    (To be included there must be stock ownership)

    Partners, Officers, Relatives, Members to be included/excluded

    Name Title/Relationship % of Ownership Duties Included / Excluded
                  
                  
                  
                  


    Prior Carrier Information/Loss History
    (please email a hard copy loss runs for the past 5 years)

    Year Carrier/Policy # Annual Premium # of Claims Amount Paid
                  
                  
                  
                  
                  


    General Questions

    1. Does applicant own, operate or lease aircraft / watercraft?

      

    2. Do operations involve any hazardous materials?

    3. Is applicant involved in any other type of business?

      

    4. Any work sublet without Certificate of Insurance?

    5. Any sub-contractors used?

      

    6. Is a formal safety program in operation?

    7. Any group transportation provided?

      

    8. Any employees under 16 or over 50 years of age?

    9. Any employees over 60 years of age?

      

    10. Any part time or seasonal employees?

    11. Any volunteer or donated labor?

      

    12. Any employees with physical handicaps?

    13. Do employees travel out of the State?

      

    14. Are athletic teams sponsored?

    15. Are pre-employment physicals required?

      

    16. Any prior coverage declined/canceled in the past 3 years?

    Please explain all "YES" answers:

    Supplemental Questions


    Hiring Practices

    1. Written Applications?

      

    2. Job Descriptions for hiring?

    3. Pre-placement physicals / medical screenings?

      

    4. Pre-placement drug testing?

    5. Drug Free workplace?

      

    6. Orthopedic back test required?

    7. Pre-employment reference check?

      

    8. Do you take applications from potential employees?

    9. Do you check references on potential employees?

      

    10. Do you hire employees by referral?

    11. Do you hire employees through recruiters?

      

    12. Do you hire through the internet?


    Benefits

    1. Health Insurance Carriers?

    2. PPO or HMO?

    3. Percentage of participating employees?

    4. Percentage of paid employees?

    5. Benefits waiting period?

    6. Employee physicals included?

    7. Paid Vacations?

    8. Paid Sick Leave?

    9. Paid Holidays?

    10. Life Insurance Provided?

    11. Disability Insurance Provided?

    12. 401 Program in place / pension plan?


    Personnel

    1. Average employee tenure?

    2. Supervisors to employee ratio?

    3. Percentage of turnover, last 12 months?

    4. What is the current hourly wage in the governing class?

    5. Current Full-Time employee count?

    6. Current Part-Time employee count?

    7. Employee count stable, increasing or decreasing?

    8. 2010-2011 Payroll History - Total Payroll?

    9. 2009-2010 Payroll History - Total Payroll?

    10. 2008-2009 Payroll History - Total Payroll?

    11. 2007-2008 Payroll History - Total Payroll?

    12. Hours of operation

    13. Any work sublet out?


    Management / Safety

    1. Injury & Illness prevention programs?

      

    2. Documented employee training?

    3. Documented facility inspections?

      

    4. Active safety Program in place?

    5. Safety incentive program in place?

      

    6. Documented Safety Meetings?

    7. Accident investigation program in place?

      

    8. Early return to work program?

    9. Modified work, when available?

      

    10. Return to full time modified work, when available?

    11. Is compensation based on piece work?

      

    12. Out of state travel / exposure?

    13. Slip and Fall Prevention Program?

      

    14. Maximum weight lifted?

    15. Any work above two stories? Maximum Height:

      

    16. Maximum weight lifted?

    17. Person responsible for safety.

      

    18. Supervisors held accountable for injuries?

    19. Violence Intervention Program?

      

    20. Drug alcohol awareness program?

    21. First aid at every site?

      

    22. # of employees at each site?

    23. Vehicle maintenance program in place?

      

    24. Are vehicles taken home at night?

    25. Are motor vehicle records checked?

      

    26. Number of vehicles / drivers?

    27. Radius of operation?

      

    28. Detailed description of your operations: Including process, equipment and tools used; describe end product.