WC Insurance Information

Worker's Compensation Information Form:
Business Information:
Business Name*
Business Entity Type*
Federal EIN #*
DBA (If Applicable)
Year Started*
DOT # (If Applicable)
Owner's Name*
Owner's Email
Phone Number
Business Physical Address*
Is the Business Mailing Address the same as the Physical Address?*

YesNo
Mailing Address
Key Company Personnel:
Full Name
Email
Phone Number
Title
Add Personnel
Full Name
Email
Phone Number
Title
Add Personnel
Full Name
Email
Phone Number
Title
Add Personnel
Full Name
Email
Phone Number
Title
Add Personnel
Full Name
Email
Phone Number
Title
Brief Description of Operations:
Tells us what your business does.
Payroll Information:
Payroll, Employees & Sub-contractors (1099's):
Payroll:
Total Company Payroll*
Total # of Employees*
Total Payroll Costs Including 1099
Company Payroll by State and Class Code:
Subcontractor Compensation:
Does your company use Sub Contractors (1099's)?*

YesNo
Do the subcontractors have their own insurance?

YesNo
Total Sub-Contractor Payroll (1099)
Owners and Officers Inclusion / Exclusion:
Work Comp allows Owners and Officers to be excluded by choice.*
Coverage Questions
Work Comp Coverage Questions:
Have you, in the past, present, or discontinued operations involved storing, treating, discharging, applying, disposing, or transporting hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)*

YesNo
Is work performed underground or above 15 feet?*

YesNo
Is the applicant engaged in any other type of business?*

YesNo
Is a written safety program in operation?*

YesNo
Is there any group transportation provided?*

YesNo
Any employees under 16 or over 60 years of age?*

YesNo
Any seasonal employees?*

YesNo
Is there any volunteer or donated labor? *

YesNo
Any employees with physical handicaps?*

YesNo
Do any employees travel out of state?*

YesNo
Are physicals required after offers of employment are made?*

YesNo
Any prior coverage declined / cancelled / non-renewed in the last three (3) years? *

YesNo
Do any employees perform work for other businesses or subsidiaries?*

YesNo
Do you lease employees to or from other employers?*

YesNo
Do any employees predominantly work at home?*

YesNo
Any tax liens or bankruptcy within the last five (5) years? *

YesNo
Any undisputed and unpaid workers' compensation premium due from you or any commonly managed or owned enterprises? *

YesNo
Best Safety & Risk Management Assessment?*

YesNo
Risk Management & Safety: Best Practices Assessment
Does your company have a dedicated Safety Director ?*

YesNo
Does your company have a written Safety policy?*

YesNo
Are employees allowed to take company vehicles home at night and/or utilize them for personal use?*

YesNo
Do you have an accident investigation process?*

YesNo
Do you maintain an accident register?*

YesNo
Does your company utilize telematic software for your fleet?*

YesNo
Does your company have a dedicated HR Director employed?*

YesNo
How often are Safety Meetings held?
Secure File Upload
Please upload the following Documents:
- Current Certificate of Insurance including any endorsements needed for contractual purposes.
- Current work comp policy (if you have one)
Accepted file types: .jpg, .pdf, .png, .xls, xlsx

Max file size: 1 GB.
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T. Hudson Risk Advisor
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Worker's Compensation Information Form:

Payroll Information:

Coverage Questions

Risk Management & Safety: Best Practices Assessment

Secure File Upload