WORKERS COMPENSATION
(Please note that these policies have required audits)
Full Legal Company Name
Physical Address (mailing if different)
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
F-EIN
Owner(s)
Name
Company Title
Included or excluded?
How many employees?
Total Payroll for previous year:
Current years estimated payroll:
Detailed Job description of each job with payroll for each:
Own, operate, or lease aircraft/watercraft?
Do past, present, or discontinued operations involve(d) in storing, treating, discharging applying, disposing or transporting of hazardous material? (e.g., landfills, waste, fuel tanks, etc.)
Perform any work underground or above 15 feet?
Perform any work on cell towers?
Engage in any other type of business?
Use subcontractors?
If yes give percent of work subcontracted
Sublet any work without Certificates of Insurance?
If a construction risk, do executive supervisors have direct supervision of labor?
if not a construction risk answer No
Use volunteer or donated labor?
Exchange labor with any other business or subsidiary?
Lease employees to from other employers?
Operate as a temporary staffing company?
Have any tax liens or bankruptcy within the last 5 years?
Have a written safety program in operation?
Have history of a loss greater than 25000?
Have multiple named insureds?
If yes to above, are the multiple named insureds combinable?
Provide an employee health plan?
Have an employee wellness program in place?
31 Have a return to work program?
Submit
Should be Empty: