General Liability Worker's Compensation PEO Commercial Auto Commercial Property

DBA: *

Fed Tax ID: * Contractors Lic#: *

Physical Address: *

City: * State: * Enter First Ltr of State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: *

Owners Name: *

Key Contact: *

Key Contact Email Address: *

Phone: *

Alternate Phone#: Fax#:

Email: *

Type of Business:

Years in Business:

Description of Operations:

(Please be a specific as possible.)

Yes No If yes with whom? Effective dates?

# of Employees Est. annual payroll Est. annual revenue

Does applicant own, operate or lease aircraft/watercraft

Yes

No

Any past, present or dicontinured operations which involve exposure to chemicals, painting, or hazardous marterials?

Yes

No

Any work performed under, on, or above water?

Yes

No

Any work which may be subjext to Jones Act, USL&H, or FELA?

Yes

No

Any work performed underground or higher than 15 feet above ground?

Yes

No

Any operations include excavation, tunneling, roadboring, earth moving, or other underground work?

Yes

No

Any operations involve exposure to radioactive/nuclear materials?

Yes

No

Any fatalities in the past five years?

Yes

No

Is applicant involved in any business other than that specified in the description of operations?

Yes

No

Does employee turnover exceed 30% annually?

Yes

No

Do employees travel out of state or out of the country?

Yes

No

Any group travel, ride-share programs, or tool or vehicle allowance provided?

Yes

No

Are physicals required after offers of employment are made?

Yes

No

Does the radius of operations vehicles exceed 200 miles?

Yes

No

Are MVRs checked on all drivers?

Yes

No

Is a "managed care" provider utilized?

Yes

No

Is a written safety program in place?

Yes

No

Has applicant been inspected by OSHA in the past three years?

Yes

No

Was applicant cited for any violations?

Yes

No

Was applicant fined?

Yes

No

Is a drug testing program in effect?

Yes

No

Is an early return/light duty program in place?

Yes

No

Does applicant "full pay" during periods of disability or reduced work?

Yes

No

Are any subcontractors used?

Yes

No

Does applicant keep copies of their Certificates of Insurance?

Any prior coverage declined, canceled or non-renewed in the past three (3) years?

Yes

No

What percentage of employees are enrolled in a group health plan?