Commercial : Work Comp

Name
Office Telephone Mobile Telephone
Mailing Address
City
Zip/Postal Code
Email Address
Business Type

Federal Employee
ID Number


Locations

Location 1
Street
City
Zip/Postal Code

Location 2
Street
City
Zip/Postal Code

Location 3
Street
City
Zip/Postal Code


Policy Information
Proposed Effective Date
Employers Liability $  each accident
$  disease-policy limit
$  disease-each employee
Other States Insured


Contact Information

Inspection:
Name
Office Telephone Mobile Telephone
Email

Accounting Records:
Name
Office Telephone Mobile Telephone
Email

Claims Information:
Name
Office Telephone Mobile Telephone
Email


Individuals Included/Excluded

Partners, Officers Relatives (must be employed by business operations) to be included or excluded.
Name
Date of Birth
Title/Relationship Ownership %
Duties

Name
Date of Birth
Title/Relationship Ownership %
Duties

Name
Date of Birth
Title/Relationship Ownership %
Duties


General Information
Does applicant own, operate or lease aircraft/watercraft?
if "yes", 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.)
if "yes", please explain
Any work performed underground or above 15 feet?
if "yes", please explain
Any work performed on barges, vessels, docks, bridges over water?
if "yes", please explain
Is applicant engaged in any other type of business?
if "yes", please explain
Are sub-contractors used?
if "yes", give % of work subcontracted
Any work sublet without certifications of insurance?
if "yes", please explain
Is a written safety program in operation?
if "yes", please explain
Any group transportation provided?
if "yes", please explain
Any employees under 16 or over 60 years of age?
if "yes", please explain
Any seasonal employees?
if "yes", please explain
Is there any volunteer or donated labor?
if "yes", please explain
Any employees with physical handicaps?
if "yes", please explain
Do employees travel out of state?
if "yes", indicate state(s) of travel and frequency
Are athletic teams sponsored?
if "yes", please explain
Are physicals required after offers of employment are made?
if "yes", please explain
Any other insurance with this insurer?
if "yes", please explain
Any prior coverage declined/cancelled/non-renewed in the last three (3) years? (not applicable in MO)
if "yes", please explain
Are employee health plans provided?
if "yes", please explain
Do any employers perform work for other businesses or subsidiaries?
if "yes", please explain
Do you lease employees to or from other employers?
if "yes", please explain
Do any employees predominantly work at home?
if "yes", list number of employees
Any tax liens or bankruptcy within the last five (5) years?
if "yes", please explain
Any undisputed and unpaid workers compensation premium due from you or any commonly managed or
owned enterprises?  
if "yes", please explain including entity name(s) and policy numbers


Line of Business


Remarks


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