Temporary Staffing Agency Questionnaire

Name: Deerfield Advisors Insurance Agency
Address: 16225 Park Ten Place, Houston, TX, 77084, US
Telephone: (281) 550-5864

Legal Name of Business
DBA
Owner Name
Main Contact Name
Fed Tax I.D.
Legal Entity
- Individual / Sole Proprietor
- Corporation
- Partnership
- Limited Liability
Physical Address (Street, City, State, ZIP)
Mailing Address (Street, City, State, ZIP)
Garaging Address (Street, City, State, ZIP)
Phone
Fax
Email
General Information
Total Number of Full Time Corporate Employees (In House)
Prior Year Actual Next Fiscal Year Projection
Total Number of Part Time Corporate Employees (In House)
Prior Year Actual Next Fiscal Year Projection
Total Number of Independent Contractors (In House)
Prior Year Actual Next Fiscal Year Projection
Corporate Employee Payroll (In House)
Prior Year Actual Next Fiscal Year Projection
Number of Contract/Temporary Placements
Prior Year Actual Next Fiscal Year Projection
Total Payroll of all Contract/Temporary Placements (do not include leasing payroll)
Prior Year Actual ($) Next Fiscal Year Projection ($)
Number of Worksites (PEO/ASO only)
Prior Year Actual Next Fiscal Year Projection
Worksites Employee Payroll (PEO/ASO only)
Prior Year Actual ($) Next Fiscal Year Projection ($)
Total Gross Receipts (deducting pass through payroll)
Prior Year Actual ($) Next Fiscal Year Projection ($)
Direct Hire Percentage of Total Revenue
Prior Year Actual (%) Next Fiscal Year Projection (%)
Applicant's Corporate Employees have been terminated or demoted in the past twelve (12) months?
Voluntary Involuntary Laid Off
Is any reduction in corporate employees anticipated within the next year?
- Yes
- No
If yes please explain:
Provide a percentage (%) breakdown of the types of staffing services offered to the Applicant's clients:
Administrative/ Clerical *
Executive
Computer/IT Services
Financial/Accounting Professionals
Janitorial
Light Industrial/ Warehouse/ Factory
Security Services (Unarmed)
Architects/Engineers without Signoff Authority
Hospitality
Teachers/ Teachers Aides
Daycare
Attorneys
Construction/Carpentry/Skilled Labor
Drivers/Transportation
Nanny Services
Teachers/ Teachers Aides
Architects/Engineers with Signoff Authority
Healthcare (excluding Doctors and Dentists}
Doctors/Dentists
*The following placements should be categorized as clerical, not IT or Financial/Accounting Professionals-accounting clerks, bookkeepers, billing clerks, medical billers/coders, filing, receptionists, data entry services.
Does the Applicant now, or will the Applicant place their employee(s) in a position which requires the employee(s) to operate:
- Yes
- No
If yes please select:
- cranes
- bulldozers
- trucks over 4,000 lbs.
- aircraft or watercraft
Does the Applicant transport temporary staffing employees to job sites?
- Yes
- No
If yes, please attach a list of drivers along with respective dates of birth and answer below:
Driver Name Date of Birth
Does the Applicant perform MVR checks at time of hire for drivers?
- Yes
- No
Does the Applicant perform annual MVR checks thereafter?
- Yes
- No
Does the Applicant specialize in clinical trial placement by recruiting participants or setting up the trials?
- Yes
- No
Does the Applicant have a hold harmless agreement in favor of the Applicant with its client companies regarding liability for employment actions of the client company?
- Yes
- No
Does the Applicant have a standard employment application for all job applicants?
- Yes
- No
Does the Applicant document the receipt of the employee handbook by the employee?
- Yes
- No
Does the Applicant have a written policy with respect to sexual harassment?
- Yes
- No
Does the Applicant have a human resource department?
- Yes
- No
If answer NO, describe how the function is handled
Does the Applicant conduct a prior employment check on all new hires?
- Yes
- No
Does the Applicant conduct criminal background checks?
- Yes
- No
Is the Applicant involved in any franchise operations?
- Yes
- No
Liability Section
Professional Liability (E&O)
Quote Requested?
- Yes
- No
E&O has been continuously in force since:
Current form type: Occurrence
If Claims Made, current retroactive date
E&O limit requested:
Deductible requested:
General Liability
Quote Requested?
- Yes
- No
Limit Requested
- $1,000,000/$2,000,000
- Other
Other Limit Requested
Damages to Premises Rented to You
- $1,000,000
- Other
Other Damages
Medical Expense
- $10,000
- $25,000
Bodily Injury/Property Damage Deductible requested
- $1,000
- $2,500
- $5,000
- $10,000
- Other
Other Deductible Requested
Stop Gap Coverage
Quote Requested?
- Yes
- No
Employee Benefits Liability (EBL) Coverage
Quote Requested?
- Yes
- No
Each Act/ Aggregate Limit
- $1,000,000/$2,000,000
- Other
Other Limit
Deductible Requested
- $1,000
- Other
Other Deductible Requested
Abuse and Molestation
Quote Requested?
- Yes
- No
Does your current insurance program include Abuse and Molestation Coverage?
- Yes
- No
Do you provide Child Care on your premises?
- Yes
- No
Do you place employees at: Day Care Centers? Schools?
- Yes
- No
Facilities with infirmed elderly?
- Yes
- No
Do you have written procedures in force for dealing with sexual abuse?
- Yes
- No
Do you have a plan of supervision that monitors staff in day to day relationships, both on and off premises?
- Yes
- No
Hired and Non-Owned Auto (HNOA) Liability
Quote Requested?
- Yes
- No
Does the Applicant obtain MVRs on all employees who drive for clients?
- Yes
- No
Does the Applicant update MVRs every year for all drivers?
- Yes
- No
Does the Applicant provide driver training or evaluation?
- Yes
- No
Does the Applicant place any long-haul drivers?
- Yes
- No
Does the Applicant place drivers that haul hazardous materials?
- Yes
- No
Does the Applicant require placements to be added to the client auto policy?
- Yes
- No
Employment Practices Liability (EPL) *EPL is not available monoline.
Quote Requested?
- Yes
- No
Limit Requested Deductible Requested
CRIME - Limits & Deductible Request
Insuring Agreement Employee Theft and Client Coverage
Requested Limit Requested Deductible
Insuring Agreement ERISA Fidelity
Requested Limit Requested Deductible
Insuring Agreement Forgery or Alteration
Requested Limit Requested Deductible
Insuring Agreement Theft, Disappearance & Destruction - Inside the Premises
Requested Limit Requested Deductible
Insuring Agreement Theft, Disappearance & Destruction - Outside the Premises
Requested Limit Requested Deductible
Insuring Agreement Money Orders and Counterfeit Paper Currency
Requested Limit Requested Deductible
Insuring Agreement Computer and Funds Transfer Fraud
Requested Limit Requested Deductible
Additional Insuring Agreement: Third Party - "Off Premises" Coverage
Requested Limit Requested Deductible
Are the Applicant's financial statements prepared by an independent Certified Public Accountant on an annual basis?
- Yes
- No
Are the owners involved in the daily operations of the company?
- Yes
- No
Are two signatures required on checks?
- Yes
- No
If YES over what amount:
lf NO who has the authority to sign checks:
Do employees who reconcile bank statements also:
sign checks?
- Yes
- No
make withdrawals?
- Yes
- No
make deposits?
- Yes
- No
have access to bank checks?
- Yes
- No
have access to computer systems that print checks?
- Yes
- No
have access to facsimile, signature plate, or check signing machines?
- Yes
- No
Will any Contract/Temporary Placements have access to client money, securities, banking systems, wire transfer systems or any sensitive computer data?
- Yes
- No
Will any Contract/Temporary Placements transport money, securities, or other valuable property outside of their client's premises?
- Yes
- No
If yes, please describe the type of property and value:
Will Contract / Temporary Placements be supervised and/or monitored by your clients when performing services on their premises?
- Yes
- No
Policy Information
General Liability
Carrier Limit Deductible Effective Date Premium
Professional Liability
Carrier Limit Deductible Effective Date Premium
Hired / NonOwned Auto
Carrier Limit Deductible Effective Date Premium
Stop Gap
Carrier Limit Deductible Effective Date Premium
EBL
Carrier Limit Deductible Effective Date Premium
Abuse & Molestation
Carrier Limit Deductible Effective Date Premium
Crime
Carrier Limit Deductible Effective Date Premium
General Summary
With respect to the coverage addressed in this application, has any Underwriter refused, canceled, or non-renewed coverage?
- Yes
- No
With respect to the coverage addressed in this Application, has the Underwriter indicated any intent to not offer renewal terms to the Applicant?
- Yes
- No
Has the Applicant given written notice under the provisions of any prior policies providing similar insurance of claims, or of specific facts or circumstances which might give rise to a Claim being made against any person or entity applying for this insurance?
- Yes
- No
No person applying for Employment Practice Liability (EPL) or Professional Liability (E&O) coverage is aware of any facts or circumstances that may give rise to a Claim under these coverages.
- Yes
- No
If answered YES please note below:
Cyber Security Liability Endorsement
Annual sales or revenue ($):
Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII) belonging to customers, clients, or other third parties, other than employees?
- Yes
- No
If yes, please indicate the types of Personally Identifiable Information held (select all that apply):
- Social Security Numbers
- Bank
- Other Financial Account Details
- Driver's License
- Other State Identification Numbers
- Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
- Credit or Debit Card Information
Cyber Security Liability Endorsement
During the last three (3) years, has anyone alleged that the Applicant was responsible for damage to their computer system(s) arising out of the operation of the Applicant's computer system(s)?
- Yes
- No
During the last three (3) years, has anyone made a demand, claim, complaint, or filed a lawsuit against the Applicant alleging invasion or interference of rights of privacy or the inappropriate disclosure of Personally Identifiable Information (PII)?
- Yes
- No
During the last three (3) years, has the Applicant been the subject of an investigation or action by any regulatory or administrative agency for privacy-related violations?
- Yes
- No
Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a claim being made against them for the coverage being applied for?
- Yes
- No
Signature*
Name*