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Application forWorkers Compensation Insurance

  • Business / Policy Information

  • Entity Type
  • Same as Mailing Address Above

  • (If more than one location is to be covered please click Add Location for each additional location.)

  • Rating Information

  • Included or Excluded?
  • Included or Excluded?
  • Included or Excluded?
  • Included or Excluded?
  • Included or Excluded?

  • (If more than one Owner / Officer is to be included/excluded please click Add Owner / Officer for each additional person.)

  • General Information

  • Does Applicant Own, Operate or Lease Aircraft / watercraft?
  • Does Applicant Have Past, Present or Discountinued Operations Involving Storing, Treating, Discharging, Applying, Disposing or Transporting Hazardous Material? (e.g. landfills, wastes, fule tanks etc)
  • Any Work Performed Underground or Above 15 Feet?
  • Any Work Performed on Barges, Vessels, Docks, Bridges Over Water?
  • Is Applicant Engaged in Any Other Type of Business?
  • Are Sub-Contractors Used?
  • Any Work Sublet Without Certificate of Insurance?
  • Is a Written Safety Program in Operation?
  • Any Group Transporation Provided?
  • Any Employees Under 16 or Over 60 Years of Age?
  • Any Seasonal Employees?
  • Is There Any Volunteer or Donated Labor?
  • Any Employees With Physical Handicaps?
  • Do Employees Travel Out of State?
  • Are Athletic Teams Sponsored?
  • Are Physicals Required After Offers of Employment are Made?
  • Any Other Insurance With This Insurer?
  • Any Prior Coverage Declined / Cancelled / Non-Renwered? (Last Three Years)
  • Are Employee Health Plans Provided?
  • Is There a Labor Interchange With Any Other Business / Subsidiary?
  • Do You Lease Employees to or From Other Employers?
  • Any Undisputed and Unpaid Workers Compensation Premium Due From You or Any Commonly Managed or Owned Enterprises?
  • Do Any Employees Predominantly Work at Home?
  • Any Tax Liens or Bankruptcy Within the Last 5 Years?

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