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you have filled in the required information, click submit
and your questionnaire will be complete. Thank you. |
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1. Legal Name:
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2. Contact Name:
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3.Governmental:
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Corporation |
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Partnership |
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LLC |
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4. Address:
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5. Phone:
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6. Email
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7. Nature of Business:
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8. Federal ID Number:
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9. Estimate of Gross Payrolls:
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10. Experience Mod:
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| **Note:
All employees and their respective gross payroll must
be included. |
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CLASSIFICATION OF OPERATIONS: |
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| Coding
and Classification of Employees |
Code #8810-Clerical: Employees who are strictly
clerical/administrative. Example: billing clerks, admitting
clerks, personnel secretaries. Can also include department
heads of clerical areas as well as administrators.
Code #7380-Drivers and their Helpers: EMTs
and full-time drivers should carry this classification.
Code #8829-Nursing Home Employees: All employees
working within the nursing home carry this classification.
If an employee works at both the nursing home and the hospital,
they should be assigned the nursing home code. NOTE:
Clerical employees within a nursing home may be classified
as 8810 if they are strictly clerical and have work places
separated from patient areas.
Code #8833-Hospital Professional Employees: All
department heads, nursing staff, ward clerks, technicians,
physical therapists, employee physicians, and those who work
with patients or in a technical area should carry this classification.
Code #8835-Home Health Employees: Employees who are
engaged in furnishing nursing or health care services in the
homes of individual patients.
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**The following questions are optional,
however in order to be provided
a firm quote all questions need to be completed.**
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| 11.
Insurance Coverage is now provided by:
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| 12.
List Partners or Corporate Officers: |
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Note: Corporate Officers, Partners and Sole Proprietors
may elect, by written agreement not to be covered. Please
indicate if Officer(s) are included or excluded in the space
provided below: |
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the appropriate line that reflects the actual and/or anticipated
exposures associated with the operations. |
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YES
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NO
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| 13.
Do you own, lease or charter any aircraft? |
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| 14.
Do you own, lease or charter any watercraft? |
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| 15.
Do/Have past, present or discontinued operations involve(d)
storing, treating, discharging, applying, disposing, or transporting
of hazardous material? (e.g. landfills, wastes, fuel tanks) |
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| 16.
Do you perform any work underground or above 15 feet? |
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| 17.
Do you engage in any other type of business? |
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| 18.
Do you use any sub-contractors? (If yes, give % of work subcontracted)
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| 19.
Any work sublet without certificates of insurance? |
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| 20.
Is a formal safety program in operation? |
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21.
Do you provide group transportation for employees to or from
the workplace?
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| 22.
Do you have any employees under 16 or over 60 years of age?
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| 23.
Do you have any seasonal employees? |
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| 24.
Do you have any volunteer or donated labor? |
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| 25.
Do you have any employees with physical handicaps? |
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| 26.
Do you have employees that travel out of state or country? |
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| 27.
Do you sponsor any athletic teams? |
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| 28.
Are physicals required after offers of employment are made? |
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29.
Has your workers' compensation coverage been canceled or
non-renewed in the past five years?
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| 30.
Are employee health plans provided? |
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| 31.
Is there a labor interchange with any other business/subsidiary? |
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| 32.
Do you lease employees to or from other employers? |
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| 33.
Do any employees predominantly work at home? |
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| 34.
Do you have any other insurance with this insurer? |
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Please provide details for any YES responses:
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(Please allow up to 20 seconds
for your message to be submitted.) |
