Workers Comp Form

GENERAL INFORMATION
Legal Name:
Corporation/LLC Partnership Individual Joint Venture Subsidiary Other
Do you operate under a d.b.a?	Yes No
d.b.a. Name:
Contact Name/Title:
Mailing Address Information
Mailing Address:		City:
State:		Zip:
Premise Address Information
Premise Address:		City:
State:		Zip:
Phone #:		Fax #:		Cell #:
Web Address:
Email Address:
Federal ID#:
*If coverage is in force please attached 4 years of currently valued Loss Runs
*Coverage Currently In Force?	Yes No
Coverage Term From:	to
State Nature of Business and Description of Business operations
List Major Owners/Shareholders
Name	Title	% Ownership




Policy Information
Year	Total Payroll	Total Premium
Current
1st Prior
2nd Prior
3rd Prior
4th Prior
Payroll Information
Position/Class Code	Payroll Per Class	Expiring Rate	# of FT/PT EMP.

Operations and Benefits
Years in Business?	Hours of Operation: to				# of Shifts:
Is there a driving/delivery exposure? Yes No		If yes, what is frequency? Daily Weekly Other:
Radius of operations/travel: <50 miles 50-100 100+
Any group transportation of employees? Yes No		If yes, how provided? Car Truck Van Bus
		# of employees transported per vehicle:
		# of vehicles used to transport:
		Frequency: Daily Weekly Monthly
Are vehicles company owned? Yes No		If yes, are vehicles taken home? Yes No
		# of vehicles?
		# of drivers?
Vehicle/fleet maintenance program? Yes No Other:		If yes, who does the servicing? Outside Vendor In-house Mechanics Other:
Do employees use personal vehicles for company business? Yes No		Do any employees work from home? Yes No
Any out of state, international or overnight (within state) travel? Yes No		If yes, please provide details:
		Why/Purpose?
		Who will travel?
		Where?
		Duration?
		Frequency?
List the # of employees who live or work out of state:		# Live:	# Work:
# of employees - Full Time: Part-Time: Seasonal: Volunteers:
# of W-2's Issued - Last Year: Previous Year:
How are employees paid? Hourly Piece Rate Commission Flat Salary Other:
Any day laborers or temporary/employee leasing? Yes No		If yes, please provide details:
% of union employees: % of non-union:				Paid sick leave? Yes No
Actual average hourly wage for employees in governing class: $/per hour				Paid vacation? Yes No
Retirement/Pension plan? Yes No	Does employer contribute? Yes No
Group medical provided? Yes No	If yes, name of healthcare provider:
	% of employees enrolled:
	% paid by employer:
Do you use a specific medical provider to treat injured employees? Yes No		If yes, name of clinic, physician, hospital, or emergency room:
CPR training provided? Yes No	# of employees certified:
RTW program? Yes No	Does it include salary continuation? Yes No
Hiring Practices - Employee Selection - Claims
Written application? Yes No	Pre-hire drug testing? Yes No
Reference check? Yes No	Post accident drug testing? Yes No
Pre/post employment physicals? Yes No	MVR checks? Yes No
Orthopedic back testing? Yes No	Audio hearing tests? Yes No
Formal job descriptions on file? Yes No	Do you have a formal written accident report? Yes No
Are personnel files documented for pre-existing injuries? Yes No	Are there a set of procedures for reporting claims? Yes No
Average claim reporting time frime:
Any interchange of labor? Yes No	If yes, please explain: Another Business Subsidiary Between Departments Other:
Is job specific training provided? Yes No
Employee Orientation Program? Yes No	If yes, is the orientation Verbal Only? Verbal and Documented?
Supervisor to employee ratio - better than 4-1 5-1 6-1 7-1 >7-1
Subcontractors used? Yes No	If yes, for what purpose?
	If yes, are certificates of insurance obtained and kept on file? Yes No
Independent contractors used? Yes No	If yes, for what purpose?
	If yes, how are they paid? 1099's Other:

Safety Program and Organization - Work Premises and Environment
Are owners active in daily operations? Yes No	If yes, are they excluded from coverage? Yes No
Active injury & illness prevention program? Yes No	Has loss control services been performed in the last year? Yes No
Active safety incentive program? Yes No	If yes, does it encompass all employees? Yes No
	What type of incentive?
Has Cal/OSHA visited or cited your business in the last year? Yes No	If yes, please provide explanation:
Are safety meetings conducted? Yes No	If yes, how often? Daily Weekly Monthly Quarterly Other:
Does employee receive safety/training orientation? Yes No	If yes, is the training Formal/Documented? Informal?
Do you have a safety director or risk manager? Yes No	Name and Title:
	If yes, is the position full time or an additional responsibility of another employee?
MSDS (Material Safety Data Sheets) available for all chemicals and products use? Yes No N/A
Any material handling exposures? Yes No	If yes, please explain:
Any lifting exposures? Yes No	If yes, <25 lbs. 25-40 40+
	If 40+, manual lifting or with assistance? Please explain:
Any forklift training provided? Yes No	If yes, annual certification? Yes No
Is all machinery/equipment properly guarded? Yes No	Any use of baler equipment? Yes No
Written lock out/tag out/block out procedures in place? Yes No N/A	Condition of equipment? New Good Average
Respiratory program in place? Yes No N/A	Are all equipment operators trained/certified? Yes No N/A
What is the maximum height at which you will work?
Personal protection equipment provided? Yes No N/A	If yes, strict enforcement of utilization? Yes No
What is used? Ladder Scaffolding Scissor Lifts N/A	If scaffolding used, does the insured build their own? Yes No
What types of PPE?
Is the building/premises owned or leased? Owned Leased	# of years at current location:
Condition of premises? Excellent Very Good Average	Age of building(s) occupied:
Retail/Wholesale
Type of merchandise?
Gross receipts: Wholesale: % Retail: %
Warehousing? Yes No
Any packaging or repackaging operations? Yes No	If yes, please explain operations:
Assembly exposure? Yes No	If yes, please explain exposure:
Any distribution exposure Yes No	If yes, by: Common Carrier?Trucking Exposure?
Automotive Services
Any towing services provided? Yes No	If yes, any contract towing? Yes No
Any road repair assistance? Yes No	If yes, 24 hour exposure? Yes No
Is there a mini-market on premises? Yes No	If yes, any sales of alcoholic beverages? Yes No
	Open 24 hours? Yes No
	Is cashier's booth bullet proof? Yes No
Any fueling operations? Yes No	Any security surveillance cameras on premises? Yes No
Any test driving of customers' vehicles? Yes No	Any transporation of customers? Yes No
Access to freeway? 0-1 mile 1-2 miles 2+ miles
Are employees ASE trained and certified? Yes No	If yes, how many employees?
Manufacturing - Machine Shops
Any punch or press brake machinery/equipment? Yes No	Machine Guarded: Point of Operation Drive Mechanism
Age of machinery: <2 yrs 2-5 yrs 5-10 yrs 10+ yrs	Accessible moving parts guarded on machinery/equipment? Yes No
Types of machines (must equal 100%) - Heavy: % Mid: % Light: %
Any Computer Network Controlled (CNC) machinery? Yes No
% of off-premise operations:	If yes, where/what for?
Is building properly ventilate? Yes No	Is proper dust collection system in place? Yes No