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Workers Compensation Questionnaire
Call Us Today At
(281) 550-5864
Workers Compensation Questionnaire
Legal Name of Business
DBA
(FEIN) Tax ID
Date Business Started
Proposed Effective Date
First Name (Primary)
Last Name
Date of Birth
Occupation
First Name (Secondary/Spouse)
Last Name
Date of Birth
Occupation
Home Phone
Mobile Phone
Work Phone
Email Address
Physical Address
Please indicate your preferred method of communication
Voice/Phone
Email
Fax
Text
SIC
NAICS
Locations
Loc#
Highest Floor
Street Addr
City
State
Zip
County
Part 1 - Workers Compensation (States)
Other Coverages
U.S.L & H
Voluntary Comp
Third Choice
Individuals Included / Excluded
Partners, Officers, Relatives (must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.)
State
Loc#
Name
DOB
Title/Relationship
Ownership%
Duties
Inc/Exc
Class Code
Remuneration/Payroll
Rating Information - State:
Loc#
Class Code
Decr Code
Categories, Duties, Classifications
Fulltime
Part Time
Amt Paid
Reserve
SIC
NAICS
Estimated Annual Remuneration/Payroll
Rate
Estimated Annual Premium
Prior Carrier Information / Loss History
Please Provide Information for the past 5 years
Year
Carrier
Policy #
Annual Premium
MOD
# Claims
Amt Paid
Reserve
Please use this section to provide Loss Details:
Nature of Business/ Description of Operations
Give Comments and Descriptions Of Business, Operations And Products: Manufacturing · Raw Materials, Processes, Product, Equipment; Contractor·Type Of Work, Sub-Contracts; Mercantile· Merchandise, Customers, Deliveries; Service· Type, Location; Farm• Acreage, Animals, Machinery, Sub-Contracts.
General Information
Does Applicant Own, Operate Or Lease Aircraft / Watercraft?
Yes
No
If yes please explain:
Do I Have Past, Present Or Discontinued operations Involve(D) Storing, Treating, Discharging, Apply Ing, Disposing, Or Transporting Of Hazardous Material? (E.G. Landfills, Wastes, Fuel Tanks, Etc)
Yes
No
If yes please explain:
Any Work Performed Underground Or Above 15 Feet?
Yes
No
If yes please explain:
Any Work Performed On Barges, Vessels, Docks, Brldge Over Water?
Yes
No
If yes please explain:
Is Applicant Engaged In Any Other Type Of Business?
Yes
No
If yes please explain:
Are Sub-Contractors Used? (If "Yes", Give% Of Work Subcontracted)
Yes
No
If yes please explain:
Any Work Sublet Without Certificates Of Insurance?
Yes
No
If yes please explain:
Is A Written Safety Program In Operation?
Yes
No
If yes please explain:
Any Group Transportation Provided?
Yes
No
If yes please explain:
Any Employees Under 16 Or Over 60 Years Of Age?
Yes
No
If yes please explain:
Any Seasonal Employees?
Yes
No
If yes please explain:
Is There Any Volunteer Or Donated Labor? (If "Yes", Please Specify)
Yes
No
If yes please explain:
Any Employees With Physical Handicaps?
Yes
No
If yes please explain:
Do Employees Travel Out Of State? (If "Yes", Indicate State(S) Of Travel And Frequency)
Yes
No
If yes please explain:
Are Athletic Teams Sponsored?
Yes
No
If yes please explain:
Are Physicals Required After Offers Of Employment Are Made?
Yes
No
If yes please explain:
Any Other insurance With This Insurer?
Yes
No
If yes please explain:
Any Prior Coverage Declined/ Cancelled / Non-Renewed In The Last Three (3) Years?
Yes
No
If yes please explain:
Are Employee health Plans Provided?
Yes
No
If yes please explain:
Do Any Employees Perform Work For Other Businesses Or Subsidiaries?
Yes
No
If yes please explain:
Do You Lease Employees To Or From Other Employers?
Yes
No
If yes please explain:
Do Any Employees Predominantly Work At Home?
Yes
No
If "Yes", # Of Employees:
Any Tax Liens Or Bankruptcy Within The Last Five (5) Years?
Yes
No
If yes please explain:
Any Undisputed And Unpaid Workers Compensation Premium Due From You Or Any Commonly Managed Or Owned Enterprises?
Yes
No
If yes, explain including entity name(s)and policy number(s).
Temp Employee Data & Client List
TEMPORARY SERVICE BRANCH OFFICES
Please complete one row for each branch office. Number of employees should be permanent staff located in that branch office.
Physical Address (No P.O.boxes)
City
State Zip
Bld # of Stories
No. of Employees by Location
No. of Work Shifts
Max No. of Employees per Shift
CLIENT COMPANIES OF TEMPORARY SERVICE
Please complete one row for each branch office. Number of employees should be permanent staff located in that branch office.
Client Company Name
Zip Code
No of Employees
Brief Description of Operations
Are there any special events during the year that would place more than 50 people at one time at one of the locations listed above, such as conventions, holiday parties, etc.?
Signature
*
Name
*
Δ
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