WORKERS COMPENSATION APPLICATION
APPLICANT NAME
Email Address
*
MAILING ADDRESS
City
State
Country
Country
Postal Code
YEARS IN BUSINESS
FEDERAL EMPLOYER NUMBER
DATE OF BIRTH
LOCATIONS
LOC #
HIGHEST FLOOR
STREET
CITY
COUNTRY
STATE
ZIP CODE
POLICY INFORMATION
EMPLOYERS LIABILITY
EACH ACCIDENT
$
DISEASE-POLICY LIMIT
$
DISEASE-EACH EMPLOYEE
$
CONTACT INFORMATION
TYPE
NAME
MOBILE PHONE
E-MAIL
INDIVIDUALS INCLUDED / EXCLUDED
NAME
OWNERSHIP %
INCLUDED / EXCLUDED
RATING INFORMATION
STATE
CLASS CODE
CATEGORIES,DUTIES,CLASSIFICATION
Number of Employees (Full Time)
Number of Employees (Part Time)
ESTIMATED ANNUAL RENUMERATION/PAYROLL
PRIOR CARRIER INFORMATION / LOSS HISTORY
CARRIER AND POLICY NUMBER
CO:
POL #:
NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS
GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES
Does applicant own, operate or lease aircraft / watercraft?
YES
NO
Please explain
Do / have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)
YES
NO
Please explain
Any work performed underground or above 15 feet?
YES
NO
Please explain
Any work performed on barges, vessels, docks, bridge over water?
YES
NO
Please explain
Is applicant engaged in any other type of business?
YES
NO
Please explain
Are sub-contractors used? (If "Yes", give % of work subcontracted)
YES
NO
Please explain
Any work sublet without certificates of insurance? (If "Yes", payroll for this work must be included in the State Rating Worksheet on Page 2)
YES
NO
Please explain
Is a written safety program in operation?
YES
NO
Please explain
Any group transportation provided?
YES
NO
Please explain
Any employees under 16 or over 60 years of age?
YES
NO
Please explain
Any seasonal employees?
YES
NO
Please explain
Is there any volunteer or donated labor? (If "Yes", please specify)
YES
NO
Please explain
Any employees with physical handicaps?
YES
NO
Please explain
Do employees travel out of state? (If "Yes", indicate state(s) of travel and frequency)
YES
NO
Please explain
Are athletic teams sponsored?
YES
NO
Please explain
Are physicals required after offers of employment are made?
YES
NO
Please explain
Any other insurance with this insurer?
YES
NO
Please explain
Any prior coverage declined / cancelled / non-renewed in the last three (3) years? (Missouri Applicants - Do not answer this question)
YES
NO
Please explain
Are employee health plans provided?
YES
NO
Please explain
Do any employees perform work for other businesses or subsidiaries?
YES
NO
Please explain
Do you lease employees to or from other employers?
YES
NO
Please explain
Do any employees predominantly work at home? If "Yes", # of employees:
YES
NO
Please explain
Any tax liens or bankruptcy within the last five (5) years? (If "Yes", please specify)
YES
NO
Please explain
Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? If "Yes", explain including entity name(s) and policy number(s)
YES
NO
Please explain
SIGNATURE
APPLICANTS SIGNATURE ( MUST BE OFFICER, OWNER, OR PARTNER )
Clear
PRODUCER'S SIGNATURE
Clear