InstagramThis field is for validation purposes and should be left unchanged.Applicant InformationApplicant Entity Type(Required) Individual Partnership Corporation LLC Joint Venture Applicant Name(Required)Applicant's Name(Required) First Last Applicant's Company Name(Required)(N/A if you don't have one)Owner's Name(Required) First Last Business Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is business address the same as mailing address?(Required) Yes No Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)FaxEmail(Required) Website FEIN (Tax ID #):(Required)Does the applicant have a DBA (Doing Business As) name:In what year did the applicant start operations?(Required)Please describe the applicant's day-to-day business operations:(Required)Main area of practice, type of services provided, products, etc. - Please be detailedAre there any locations or business interests that are owned by the applicant but not shown on the application?(Required) Yes No If Yes, please describe in detail:(Required)Are you an existing entity seeking a new policy, or a new venture (no previous policies)?(Required) Existing New If New, please describe in detail:(Required)Does applicant own any business autos?(Required) Yes No If Yes, please describe in detail:(Required)Has the applicant or any principal of the business declare bankruptcy in the last seven years?(Required) Yes No If yes, provide name, date filed, court case, case number, chapter, status:(Required)List all physical locations where employees perform work:(Required) Add RemoveConstruction type:(Required) Frame Joisted Masonry Non-Combustible Modified fire resistive Age of building:(Required)Number of floors:(Required)Seismically retrofitted?(Required) Yes No Payroll(Required)Expiring Year1st Prior Year2nd Prior Year3rd Prior YearPremium(Required)Expiring Year1st Prior Year2nd Prior Year3rd Prior YearAre any employees working remotely or from home?(Required) Yes No If so, describe their duties and how their work environment is managed for safety:(Required)Do employees regularly work out of state?(Required) Yes No If so, which states and for what purpose/duration?(Required)What is the value of your business personal property? (BPP are all your furniture, computers, printers, etc. Basically, anything you will take with you if you move)(Required)Employee InformationTotal number of employees:(Required)Full-time:(Required)Part-time:(Required)Seasonal:(Required)Independent Contractors:(Required)Do you use temporary or leased employees?(Required) Yes No If yes, please provide details:(Required)Do you provide health benefits to employees?(Required) Yes No How many employees work at each location?Single Location(Required)Multiple Locations(Required)Remote Work(Required)Do employees travel for work purposes?(Required) Yes No If yes, how often and for what purpose?(Required)Payroll & Classification InformationEstimated annual payroll for all employees:(Required)Employee job classifications and payroll breakdown:(Required)Job TitleNumber of EmployeesAnnual PayrollDescription of Duties Add RemoveAre there any "special" employees like Executive Officers, Partners, LLC Members?(Required) Yes No Are they to be included or excluded from coverage?(Required) Included Excluded If included, what is their payroll?(Required)Do you utilize subcontractors or independent contractors?(Required) Yes No For each, do you obtain certificates of insurance (COIs) showing their own Workers' Compensation coverage?(Required) Yes No What is the annual cost of subcontractors without a valid WC COI? (This payroll may be added to your policy for premium calculation).(Required)What is the nature of the work performed by these subcontractors?(Required)Do you have a copy of each subcontractor’s license number?(Required) Yes No Do employees operate machinery or heavy equipment?(Required) Yes No Do employees handle hazardous materials?(Required) Yes No If yes, please describe:(Required)AutomobilesBusiness operations include driving by employees for the following employees: Add RemoveDelivery(Required) Yes No Frequency of Delivery(Required) Daily Weekly Other Radius(Required)Travel to or between Jobsites/Facility Location(Required) Yes No Vehicle inspection/maintenance program(Required) Yes No Vehicle maintenance is performed by employees(Required) Yes No Employees take company vehicles home at night(Required) Yes No Operations / PracticesPaid Time Off (PTO), Vacation, and Sick Time Programs:(Required) Yes No Employee Assistance Program:(Required) Yes No Medical / Healthcare Insurance for Employees:(Required) Yes No Dental Insurance for Employees:(Required) Yes No Vision Insurance for Employees:(Required) Yes No Supplementary Disability Insurance for Employees:(Required) Yes No Employee Retirement Plan / Pension Plan / 401k for Employees:(Required) Yes No Check all of the hiring practices implemented by the applicant:(Required) Written job description Employee orientation/training Harassment Prevention Protocols Drug-free Workplace Periodic Performance Reviews Exit Interview Check all of the following practices implemented by the applicant:(Required) Injury and Illness Prevention Program Outdoor Heat Control Plan Ladder Safety Plan Emergency Response Plan Blood-borne Pathogens Safety Program Respiratory Protection Plan Confined Spaces Plan Driver Safety Plan Disaster Recovery Plan Hearing Loss Prevention Plan Fall Protection Plan Forklift Safety Plan Safety & Risk ManagementDo you have a written workplace safety program?(Required) Yes No Do employees receive regular safety training?(Required) Yes No Does applicant track and document safety efforts and safety training?(Required) Yes No Does applicant provide necessary safety (personal protective) equipment to employees and any necessary training for the equipment?(Required) Yes No Does applicant provide safety incentives for employees who achieve compliance?(Required) Yes No Does applicant enforce disciplinary consequences for employees who violate safety procedures?(Required) Yes No Do you conduct background checks on new hires?(Required) Yes No Do you conduct drug testing before or during employment?(Required) Yes No Do you have an established return-to-work program for injured employees?(Required) Yes No Do you have a designated safety officer or risk manager?(Required) Yes No If yes, please provide their name and title:(Required)Are new employees provided with safety orientation and specific job hazard training?(Required) Yes No Is personal protective equipment (PPE) provided and enforced (e.g., hard hats, safety glasses, gloves, respirators)?(Required) Yes No What is the process for reporting workplace hazards and near misses?(Required)Are regular safety inspections conducted (internal or external)?(Required) Yes, Internal Yes, External Yes, Both No Inspections Conducted What is your hiring process? Do you conduct background checks?(Required)Are physical examinations or fitness-for-duty tests required for certain roles?(Required) Yes No Claims History & Current CoverageDo you currently have workers' compensation insurance?(Required) Yes No If yes, name of current insurer:(Required)Policy expiration date:(Required)Current policy limits:(Required)Please provide currently valued loss runs for the past 3-5 years for Workers' Compensation. These should include:(Required)Policy Period DatesTotal incurred losses (Paid+Reserves)# of Claims (Open and Closed)Description of each claim (injury type, body part, cause, date of injury)Status of Open ClaimsExperience Modification Factor (N/A if not applicable) Add RemoveHave any previous Workers' Compensation policies been declined, cancelled, or non-renewed? If yes, please explain the circumstances.(Required) Yes No If yes, please explain the circumstances.(Required)What measures have been implemented to prevent recurrence of past claims?(Required)Additional Coverage & EndorsementsWould you like to include coverage for the following? (Check all that apply)(Required) Employer’s Liability Coverage Waiver of Subrogation Occupational Accident Insurance Coverage for Out-of-State Employees Other (please specify): Other (please specify):(Required)Desired Effective Date:(Required) MM slash DD slash YYYY Requested Coverage Limits:(Required)Requested Deductibles:(Required)Additional Comments or Special Considerations(Please provide any other relevant information that may impact your insurance coverage needs.) Δ
