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Workers Compensation Application

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Workers Compensation Application

Firm:

Contact Name:*

Your Email:*

Location Address: City:

State:

Zip:

Mailing Address (If different): *Multiple Locations: Please Provide A Separate Form for Each State. Description of Operations: Does The Firm Work or Travel Outside The State? YesNo If Yes, Please Identify The States and The % of Total Work Performed: States:   Percentage of Total Work:

Organization: INDIVIDUALPARTNERSHIPCORPORATIONOTHER If Other: 

OWNERS' / OFFICERS' / DIRECTORS' PAYROLL INFORMATION BELOW

Note: It is our recommendation that all principals include themselves to be covered by the workers' compensation policy. *Requirements for exclusion of corporate officers/directors 1) 100% of stock must be held within the corporate officer structure (closed corp.) and 2) the individual officer/director to be excluded must own stock. __ Owner/Office/Director #1 Name:

Include or Exclude* from Coverage: EXCLUDEINCLUDE Title:

Duties: Class Code:

Percentage of Ownership: (should total 100%)

Payroll: (Minimun $45,000 Maximum $117,000)

  __ Owner/Office/Director #2 Name:

Include or Exclude* from Coverage: EXCLUDEINCLUDE Title:

Duties: Class Code:

Percentage of Ownership: (should total 100%)

Payroll: (Minimun $45,000 Maximum $117,000)

  __ Owner/Office/Director #3 Name:

Include or Exclude* from Coverage: EXCLUDEINCLUDE Title:

Duties:

Class Code:

Percentage of Ownership: (should total 100%)

Payroll: (Minimun $45,000 Maximum $117,000)

  __ Owner/Office/Director #4 Name:

Include or Exclude* from Coverage: EXCLUDEINCLUDE Title:

Duties: Class Code:

Percentage of Ownership: (should total 100%)

Payroll: (Minimun $45,000 Maximum $117,000)

  __ Owner/Office/Director #5 Name:

Include or Exclude* from Coverage: EXCLUDEINCLUDE Title:

Duties: Class Code:

Percentage of Ownership: (should total 100%)

Payroll: (Minimun $45,000 Maximum $117,000)

 

ALL OTHER EMPLOYEES' PAYROLL BELOW * DO NOT INCLUDE THE ABOVE OWNERS' / DIRECTORS' PAYROLL BELOW

JOB CLASSIFICATION:

PAYROLL:

ESTIMATED ANNUAL:

8601(1) Engineers, Architects, Land Surveyers ENGINEERS - consulting - mechanical, civil, electrical and mining engineers and architects - not engaged in actual construction or operation - including Outside Salespersons and Clerical Office Employees. # of full time employees:

# of part time employees:

 

TOTAL ESTIMATED ANNUAL PAYROLL (included #1 owners/officers + #2 Employees)

1. Federal Identification Number:

Years in Business:

2. If new clients to IOA, specify current work comp Insurance co.* a. How many WC loss over the past 3 years?

What kind?  *Also, please provide loss history report from your insurance company for the last 5 years. Title:

 Date:

______  

FIRM: 

DATE: 

 

PLEASE EXPLAIN ALL YES ANSWERS

1) Any aircraft/watercraft owned, operated or leased? YESNO If yes:  2) Any operations involving storage, treatment, discharging, applying, disposing of, or transporting hazardous material in the past, in the present, or planned for the future? YESNO If yes:  3) Any Work performed underground or above 15 feet? YESNO If yes:  4) Any work performed, or anticipated to be performed, on barges, vessels, docks, bridges, or over water? YESNO If yes:  5) Is applicant engaged in any other type of business? YESNO If yes:  6) Are subconsultants used? YESNO If yes, what percentage:

What services used? 7) Are subconsultants employers Liability (WC) limits required to equal or exceed your Employers Liability (WC) limits? YESNO If yes:  8) Any work sublet without certificates of insurance? YESNO If yes:  9) Is a formal safety program in operation? YESNO If yes:  10) Any group transportation provided? YESNO If yes:  11) Any employees under 16 or over 60 years of age? YESNO If yes:  12) Any seasonal employees? YESNO If yes:  13) Is there any volunteer or donated labor? YESNO If yes:  14) Any employees with physical handicaps? YESNO If yes:  15) Do your employees travel out of the state or out of the country on business? YESNO If yes:  16) Are athletic teams sponsored? YESNO If yes:  17) Are physicals required after offers of employment are made? YESNO If yes:  18) Are employee health plans provided? YESNO Carrier:  19) Is there a labor interchange with any other business/subsidiary? YESNO If yes:  20) Do you lease employees to, or from, other employers? YESNO If yes:  21) Do any employees predominantly work at home? YESNO If yes:  22) Are workstations ergonomically designed at all locations? YESNO If yes:  23) Are all employees provided with training/education on ergonomic issues? YESNO If yes:  24) Any other insurance with this insurer? YESNO If yes:  25) Has any policy or coverage been declined, canceled or non-renewed in last 3 years? YESNO If yes:  26) Any tax liens or bankruptcy within the last 5 years? YESNO If yes:  Contact for accounting records:  Phone Number:

Contact for claims information:

Phone Number:

 

Foreign Liability Coverage Questionaire

1. What countries is the insured traveling to? (Please be specific of the County) Give description of what the insured will be doing?  2. How many trips will be taken throughout the year?

3. How many employees does the insured estimate will travel through the year?

4. How many employees will be traveling on each trip?

5. What is the longest duration of any trip?