THE PEOple Company
Client Underwriting & Onboarding Submission Packet
Where People Power Business
Applicant Information:
Company:
Date:
-
Month
-
Day
Year
Date
Owner Name:
First Name
Middle Initial
Last Name
Eff Date:
-
Month
-
Day
Year
Date
Phone:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
FEIN:
Year(s) in Business:
States Operating In:
Broker Name:
Broker Information (if any):
Broker Name:
Workers' Compensation Profile:
Description of Operations:
Scope of Work:
Workers' Compensation Payroll by Code Information
Employee Job Description:
Total Weekly Payroll:
Total # of Employees:
State/Code:
1
2
3
4
5
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Where People Power Business
Current & Previous Coverage Information
Current & Previous Coverage Information
Total # of Claims:
Total # of Employees:
Claim $ Incurred:
CURRENT POLICY TERM
PREVIOUS YEAR 1
PREVIOUS YEAR 2
PREVIOUS YEAR 4
PREVIOUS YEAR 5
General Risk & Operations Disclosure:
Yes No Explanation
Own, operate, or lease aircraft/watercraft?
Yes
No
Exposure to chemicals, lead-based paint, hazardous materials?
Yes
No
Work under, on, or above water?
Yes
No
Work subject to Jones Act, USL&H, or FELA?
Yes
No
Work underground or over 15 ft above ground?
Yes
No
Excavation, tunneling, road boring, earth moving?
Yes
No
Any fatalities in past 5 years?
Yes
No
Any other business operations not described?
Yes
No
Employees travel out of state or country?
Yes
No
Group travel or ride-sharing programs provided?
Yes
No
Vehicle radius exceeds 200 miles?
Yes
No
MVRs checked on all drivers?
Yes
No
Written safety program in place? (Attach copy)
Yes
No
OSHA inspection in past 3 years?
Yes
No
OSHA citations?
Yes
No
OSHA fines?
Yes
No
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THE
PEOPLE
COMPANY
Where People Power Business
General Risk & Operations Disclosure:
Yes No Explanation
Subcontractors used?
Yes
No
Roofing work performed?
Yes
No
Prior coverage declined/cancelled/non-renewed in past 3 years?
Yes
No
Do you perform work with height exposure? (If yes, please provide maximum height worked in explanation)
Yes
No
Commercial Work? (If yes, please provide percentage of total work performed in explanation)
Yes
No
Residential Work? (If yes, please provide percentage of total work performed in explanation)
Yes
No
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Workers' Compensation Loss History Affidavit
I, ____________________________________, do hereby verify and swear that (Company Name) ____________________________________ has incurred ________ injuries within the last 36 months.
Please list the injuries and the costs incurred in the table below for the last 36 months: (Note: If there no injuries, write N/A in the table below.)
Current & Previous Coverage Information
Total # of Claims:
Total # of Employees:
Claim $ Incurred:
CURRENT POLICY TERM
PREVIOUS YEAR 1
PREVIOUS YEAR 2
PREVIOUS YEAR 4
PREVIOUS YEAR 5
Explanation Required:
If an individual claim exceeds >$15,000.00
By signing below, I attest that the claims information provided is accurate to the best of my knowledge. I further attest that no outstanding premiums are owed to any Professional Employer Organization or insurance carrier.
Company Name:
Signature:
Title:
Date:
-
Month
-
Day
Year
Date
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