Automotive Specialty Insurance

Workers Comp Form

Main Content of the Workers Compensation Form and Link to the PDF Application.

GENERAL INFORMATION
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#:
Coverage Term From: to
List Major Owners/Shareholders
Name Title % Ownership
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? If yes, what is frequency?
Radius of operations/travel:
Any group transportation of employees? If yes, how provided?
# of employees transported per vehicle:
# of vehicles used to transport:
Frequency:
Are vehicles company owned? If yes, are vehicles taken home?
# of vehicles?
# of drivers?
Vehicle/fleet maintenance program?
If yes, who does the servicing?
Do employees use personal vehicles for company business? Do any employees work from home?
Any out of state, international or overnight (within state) travel? 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?
Any day laborers or temporary/employee leasing? If yes, please provide details:
% of union employees: % of non-union: Paid sick leave?
Actual average hourly wage for employees in governing class: $/per hour Paid vacation?
Retirement/Pension plan? Does employer contribute?
Group medical provided? If yes, name of healthcare provider:
% of employees enrolled:
% paid by employer:
Do you use a specific medical provider to treat injured employees? If yes, name of clinic, physician, hospital, or emergency room:
CPR training provided? # of employees certified:
RTW program? Does it include salary continuation?
Hiring Practices - Employee Selection - Claims
Written application? Pre-hire drug testing?
Reference check? Post accident drug testing?
Pre/post employment physicals? MVR checks?
Orthopedic back testing? Audio hearing tests?
Formal job descriptions on file? Do you have a formal written accident report?
Are personnel files documented for pre-existing injuries? Are there a set of procedures for reporting claims?
Average claim reporting time frime:
Any interchange of labor? If yes, please explain:
Is job specific training provided?
Employee Orientation Program? If yes, is the orientation
Supervisor to employee ratio - better than
Subcontractors used? If yes, for what purpose?
If yes, are certificates of insurance obtained and kept on file?
Independent contractors used? If yes, for what purpose?
If yes, how are they paid?
Safety Program and Organization - Work Premises and Environment
Are owners active in daily operations? If yes, are they excluded from coverage?
Active injury & illness prevention program? Has loss control services been performed in the last year?
Active safety incentive program? If yes, does it encompass all employees?
What type of incentive?
Has Cal/OSHA visited or cited your business in the last year? If yes, please provide explanation:
Are safety meetings conducted? If yes, how often?
Does employee receive safety/training orientation? If yes, is the training
Do you have a safety director or risk manager? 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?
Any material handling exposures? If yes, please explain:
Any lifting exposures? If yes,
If 40+, manual lifting or with assistance? Please explain:
Any forklift training provided? If yes, annual certification?
Is all machinery/equipment properly guarded? Any use of baler equipment?
Written lock out/tag out/block out procedures in place? Condition of equipment?
Respiratory program in place? Are all equipment operators trained/certified?
What is the maximum height at which you will work?
Personal protection equipment provided? If yes, strict enforcement of utilization?
What is used? If scaffolding used, does the insured build their own?
What types of PPE?
Is the building/premises owned or leased? # of years at current location:
Condition of premises? Age of building(s) occupied:
Retail/Wholesale
Type of merchandise?
Gross receipts:    Wholesale: %    Retail: %
Warehousing?
Any packaging or repackaging operations? If yes, please explain operations:
Assembly exposure? If yes, please explain exposure:
Any distribution exposure If yes, by:
Automotive Services
Any towing services provided? If yes, any contract towing?
Any road repair assistance? If yes, 24 hour exposure?
Is there a mini-market on premises? If yes, any sales of alcoholic beverages?
Open 24 hours?
Is cashier's booth bullet proof?
Any fueling operations? Any security surveillance cameras on premises?
Any test driving of customers' vehicles? Any transporation of customers?
Access to freeway?
Are employees ASE trained and certified? If yes, how many employees?
Manufacturing - Machine Shops
Any punch or press brake machinery/equipment? Machine Guarded:
Age of machinery: Accessible moving parts guarded on machinery/equipment?
Types of machines (must equal 100%) - Heavy: %   Mid: %   Light: %
Any Computer Network Controlled (CNC) machinery?
% of off-premise operations: If yes, where/what for?
Is building properly ventilate? Is proper dust collection system in place?
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