Workers Compensation Application
Best Viewed in 800x600 Screen Resolution

Applicant Information
Company Name:
DBA:
Street Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
Website:
Years in business:
Years in industry:
Federal ID #

State the nature of business / description of operations:
Locations
#
  Street, City, County, State, Zip
List other states you have workers compensation:

Current number of employees:
Fulltime: Part time: Seasonal:
- under the age of 18 -Over the age of 65

If the company is a sole proprietorship does it employ relatives who reside with the owner? yes No
Do any employees work from their home? yes No
Total number of W2s filed last year:
How many vehicles does the company own?
How many employees' job descriptions include driving for the company?
Are motor vehicle records checked annually? yes No
Does the company use subcontractors? yes No
If yes, are Certificates of Insurance required from each subcontractor? yes No
Please list any trade group or industry association memberships:
 
Prior Insurance Carrier Information
Carrier Name Period of coverage Policy Number Number of Claims
 
Payroll Information
Class Payroll Description
 
Corporate Officers/Partners to be Excluded
Name Title Ownership % Annual Salary DOB
% $
% $
% $
% $
 
Prior Carier Information / Loss History (Provide Last Five Year Loss History And Details)
Year Carrier Policy Number Annual Premium # Of Claims Amount Paid
$ $
$ $
$ $
$ $
$ $
 
Insured history
Is group medical provided? yes No
% paid by employer
Name Of Provider
% of full time employees on payroll for last 24 months / last 12 months
Do you use a specific medical provider to treat injured employees
Is this a clinic, physician, emergancy room, or other please specify
Do you have a light duty plan? With full pay?
Do you have a return to full time modified work plan?
Average hourly wage?
 
Hiring practices
Complete application? yes No
Reference checks? yes No
Pre/post employement physical? yes No
Motor vehicle record check? yes No
Drug/substance abuse test? yes No
Audio testing? yes No
Orthopedic back test? yes No
Pathogenic test (i.e. Lead) yes No
 
Operations
Hours of operation?
How many shifts?
Does the insured deliver? yes No Frequency Delivery radius
Vehicles owned? yes No     
Are vehicle taken home? yes No
Are vehicle inspected: how often?
Vehicle maintance program? yes No
Driver MVR “pull” program? yes No
Written sb198 program? yes No
Incentive program? yes No
Saftey director full time? yes No
Are supervisiors held accountable for injuries/accidents? yes No
Saftey meatings held fo all employees? yes No
Cpr training? yes No
Violence intervetion training? yes No
Drug awarness program? yes No
Out of state travel? Frequency? yes No 
Condition of premisis? Excellent, good, poor.
Equipment? Excellent, good, poor.
Was this operation all or part of an existing business that was purchased or accuired?
If yes, please describe the following:  what % of the business was accuired? Date ownership changed? Prior business owners name, address, name of business? Is the prior owner relationship? Has the operations changed since the business was accuired (from a bakery to a restaurant)? Are more than 50% of the current employees hired since the busines was accuired? Are the new emplyees earning more than 50% of the payroll?
Has any principal of the business declared bankruptcy in the last seven years? yes No
If yes, name of principal? Chapter of bankruptcy filed, 7, 11, 13, other.

Date filed? Case number, status – pending, dismissed, discharged. Court where case was filed?
Please let us know the best time to contact you?
Referral by:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.