workers compensation supplemental application business_wc_supplemental_applic… · workers...

Workers Compensation Supplemental Application (To be Completed with Acord 130 application)

Named Insured:

Insured's FEIN:

Web Address:

Contact Name and Phone Number

Inspections:

Premium Audit:

Claims:

( )

)(

)(

-

-

-

Prior Payroll and Premium Information

Current Year:Total Annual Payroll Premium $

Prior Year

Prior Year

Prior Year

Prior Year

Operations and Benefits

Broker Controlled Account?

Please provide a description of the operation:

Years in business?: Hours of Operation: to

NoYes

Yes No

# of Shifts: Does the applicant ever allow employees to work more than 3 consecutive 12 hour shifts?

Is there a driving/delivery exposure?

If yes, what is frequency?

Is a PUC/DMV filing required?

Are vehicles company owned?

If yes, types of vehicles:

If yes, are vehicles taken home?

# of vehicles:

Vehicle/fleet maintenance program?

If yes, who does the servicing?

Do employees use personal vehicles for company business?

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No

Daily Weekly Other:

N/A DMVPUC

Other: In-house mechanics Outside Vendor

Any out of state, international or overnight (within state) travel?

If yes, please provide details:

Why/purpose?

Who will travel?

Where?

Duration?

Frequency?

Tangram Insurance Services, Inc. of 9

100+ 50-100 < 50 milesRadius of Operations/travel:

Any group transportation of employees?

NoYes

Yes No

If yes, how provided? Van TruckCar Bus

# of employees transported per vehicle:

# of vehicles used to transport:

Monthly Weekly DailyFrequency:

Do any employees work from home?

List the # of employees who live or work out of state:

Live Work

# of employees: Full time: Part time: Seasonal: Volunteers: (Verify number is consistent with number on Acord App)

# of employees per location: #1 #2 #3 #4 (If more space is needed please use separate page)

# of W-2's issued: Last Year: Previous Year:

Any day laborers or temporary/employee leasing?

Yes No

NoYes

Yes No

If yes, please provide detail on separate page.

% of union employees: % of non-union employees:

How are employees paid? Hourly Piece Rate Commission

Flat Salary Other:

Paid Sick Leave?

Actual average hourly wage for employees in governing glass $ /hour Paid Vacation?

Retirement / Pension Plan? NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No

NoYes

NoYes Yes No

Yes No Yes NoYes

Yes No Yes NoYes

Yes No Yes NoYes

Yes No Yes NoYes

Yes No Yes NoYes

Yes No

Yes No

Yes No

Yes No

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No

Yes No Does employer contribute?

Group Medical Provided?

If yes, name of healthcare provider:

% of employees enrolled:

% paid by employer:

Do you use a specific medical provider to treat injured employees?

Are you currently participating in a MPN (Medical Provider Network)?

If yes, provide the name of current MPN:

CPR training provided?

# employees certified:

Has the ownership of the applicable entity changed within the past 5 years?


RTW Program?

Does it include salary continuance?

Hiring Practices - Employee Section - Claims


Written applications? Pre-hire drug testing?

Post Accident drug testing?Reference checks?

MVR checks?Pre/post employment physicals?

Audio hearing tests?Orthopedic back testing?

Do you have formal written accident reports?Formal job descriptions on file?

Are there set procedures for reporting claims?Are personnel files documented for pre-existing injuries?

Any interchange of labor?Average claim reporting time frame:

Is job specific training provided?

Employee Orientation Program?

If yes, is the orientation Verbal Only? Verbal and Documented?

Employee to Supervisor Ratio: Better than 4-1 5-1 6-1 7-1 >7-1

Subcontractors used? If yes, for what purpose?

If yes, are certificates of insurance obtained and kept on file?

Independent Contractors Used? If yes, for what purpose?

If yes, how are they paid? 1099's? Other? Please explain:

Safety Program and Organization - Work Premises and Environment

Active injury & illness prevention program?

Are owners active in daily operations?

Has Cal/OSHA visited or cited your business in the last year?

Has loss control services been performed in the last year?

If yes, are they excluded from coverage?

of 9Tangram Insurance Services, Inc.

If yes, please explain: Another business Subsidiary

between departments Other:

If yes, please provide explanation on separate page.


Yes No

NoYes

Yes NoActive safety incentive program? Are safety meetings conducted?

If yes, does it encompass all employees?

What type of incentive?

If yes, how often? Daily Weekly Monthly Quarterly

Other

Do employees receive safety training/orientation?

Yes No

N/ANoYes

NoYes

NoYes N/ANoYes

NoYes

N/ANoYes NoYes

Yes No N/A

N/AYes No

New Good Average

NoYes N/A

N/ANoYes

Excellent Very Good Average

NoYes

LeasedOwned or

NoYes

NoYes NoYes

NoYes NoYes

NoYes

NoYes NoYes

NoYesNoYes

NoYes

NoYes

NoYes

Yes No

NoYes

NoYes

NoYes

Yes No

If yes, is the training: Formal/Documented Informal

Do you have a safety director or risk manager? Name / Title:

If yes, is the position full time or an additional responsibility of another employee?

MSDS (Material Safety Data Sheets) available for all chemicals and products used?

Any material handling exposures? If yes, please explain:

Any lifting exposures? If yes, <25 lbs 25-40 40+ Forklift Training Provided?

If yes, annual certification?If 40+, manual lifting or with assistance? Please explain:

Is all machinery/equipment properly guarded? Any use of Baler equipment?

Written Lock out/ tag out / block out procedures in place?

Respiratory program in place?

What is the maximum height at which you will work?

Condition of equipment?

Are all equipment operators trained / certified?

Personal protection equipment provided?

What is used?

If scaffolding used, does the insured build their own?

Is the building / premises:

Condition of premises?

Ladder Scaffolding Scissor Lifts N/A If yes, strict enforcement of utilization?

What types of PPE?

# of years at current location?

Age of building occupied? years

Agriculture - Farming

Is harvesting mechanized or manual?

Do you use contracted labor?

Any seasonal workers used for operations?

If yes, provide details of when season begins and ends, # of seasonal employees hired, and if same employees used each season

Are employees transported by any vehicles on or off the premises?

Any use of pesticides or fertilizers?

If yes, applications by

Do any family members work in operations?

If yes, % of use?

Is housing provided?

If yes, # of employees housed:

Does all farm machinery have safety guards intact?

If yes, please explain on separate page.

Any crop dusting operations?

If yes, services provided by

Any work off premises? If yes, please explain on a separate page

Employees? Vendors?Vendors?Employees?

Dairy Farms:

What is the size of dairy herd? Number of Bulls over 3 years old?

Does risk grow their own feed?

Is milking barn:

Are employees allowed to enter stem pipes around lagoon?

Are proper safety procedures in place for working near stem pipes, lagoons, or sump pumps?

Are confined spaces exposures? If yes, please provide details on separate page - include copy of written procedures and details of Confined Spaces Training

Flat? Elevated?

Average number of milkings per day?

Does risk deliver any of their own milk products?

Protective Barriers?

Do any employees conduct or complete work on sump pumps?


Automotive Services

Any towing services provided?

If yes, any contract towing?

Is there a mini-market on premises?

If yes, any sales of Alcoholic beverages?

Open 24 hours?

Is cashier's booth bullet proof?

Access to Freeway?

Any off premises or mobile services?

Any road repair assistance?

If yes, 24 hour exposure?

Any fueling operations?

Any security/surveillance cameras on premises?

Any test driving of customers' vehicles?

Any transportation of customers?

NoYes

Yes No

NoYes

NoYes

NoYes

NoYes

Yes No

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No

0-1 miles 1-2 miles 2+ miles

If yes, provide details including percentage of payroll dedicated:

Any vehicle crushing operations?

Do you have a ventilated/filtered spray booth for painting operations?

Do you have a written respiratory protection program?

If yes, do employees complete a medical evaluation questionnaire?

If medical evaluation questionnaire completed, is it reviewed by a physician?

Are employees properly trained in the use and care of respiratory protection equipment?

Has proper fit testing been provided to each employee and their assigned respirator?

Any work performed on vehicles greater than 2.5 ton capacity?

Are employees ASE trained and certified?

N/ANoYes

N/ANoYes

Yes No N/A

If yes, how many employees?

Contractors

Contractors License Number? Years experience in trade?

Estimated annual gross sales? Estimated # of jobs per year?

Percentage of work sub-contracted out? % What type?

If subs used, does insured: Check annually? Directly supervise subs?

Average # of certificates collected annually? Average # of Waiver of Subrogation needed?

Indicate % of work conducted in each of the following operations (must equal 100% for each):

New Construction1)

2)

3)

Commercial

Interior

Apts/Condos/Track Homes

Exterior

Remodeling

Single Custome Homes

Service/Repair

If exterior work done, what is the maximum height exposure?

Any use of cranes, booms or similar heavy construction equipment?

Any work below grade?

Any confined spaces exposures?

Yes No

NoYes

NoYes

NoYes

NoYes

Yes No

Max Depth in feet % of total work

If yes, please provide details on separate page - include copy of written procedures and details of Confined Spaces Training

Any work involving asbestos, hazardous product abatement, chemical/petroleum products, USL&H, underground tank or pipe replacement?

If yes, please explain

Does this risk conduct work for the government or city municipality?

Is the applicant involved in "Wrap Up" or "OCIP" projects? If yes, please provide percentage of total payroll dedicated to these projects, and advise detailed procedures on how applicant determines employee split between these projects and other contracts/projects (not involving "wrap up" or "OCIP".)



Not ApplicableIndicate % of work conducted in each of the following operations or mark not applicable:


Blasting

Grading

Asbestos

Sewer

Supervisory Only

Drilling

Wrecking

Highway Work

Exterior Framing

Street/road work

Light Pole Work

Multi Story Buildings

Scaffold set-up

Structural Steel

Spray painting

Demolition

Gas Mains

Roofing

Bridge Work

Dock/Sea Walls

Tunneling

Crane Work

Concrete Tilt Up

Excavation

Apartment Ops / Building Ops / Hotel/Motel

Is housing provided? If yes, # of employees housed and describe their responsibilities:

Any furnished apartments available? If yes, % of units furnished:

Are employees involved in property maintenance? If yes, provide details:

Security Guards employed?

Does management collect payment from resident and/or is banking controlled by employee(s)?

Are employees responsible for eviction notification and/or enforcement?

Number of guest rooms?

Any shuttle, limo or similar service?

Any restaurant exposures?

Any entertainment provided?

Housekeeping exposures: Moving of furniture:

If yes, how often and # of employees involved in process?

If yes, provide details (i.e. armed or unarmed, hours on premises):

NoYes

NoYes

NoYes NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes NoYes

NoYes

NoYes NoYes

Yes No

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No

%

Security cameras or other security devices on premises?

Room rates: $100+$50-$100<$50 Rent rooms: MonthlyWeeklyDaily

If yes, please explain:

Does it include 24 hour room service?


Bar of Lounge Area?

Mattress flipping or rotating?

Janitorial

Check appropriate exposures in the following areas:

Hospitals Airports Office Buildings Stores Fire/Flood/Restaurants

Manufacturing PlantsHotelsMedical OfficesMuseumsGovernment

Apartment HousesNursing HomesEducation Facilities

Indicate % of services provided (must equal 100%):

Pressure or steam washing operations

Servicing/cleaning of hoods/filters/grease traps/etc

Aircraft service and maintenance

Heating, A/C ventilation service

Exterior window cleaning above 1st floor

Crime scene clean-up

Fire/flood restoration

Landscaping

Parking lot cleaning

Debris Clearing

Floor waxing and refinishing

Maid/housekeeping services

Elevator maintenance

Ceiling Tile cleaning

Chimney cleaning

Pest control

Snow removal

Carpet cleaning

Industrial cleaning

General cleaning*

*General Cleaning includes operations such as vacuuming, dusting, wastebasket trash pick up, floor and rug cleaning, restroom clean up

Does employee work in pairs or more? Employees supervised? Direct or Roving supervision?

Landscaping

Any tree trimming performed that is performed off the ground?

Any use of tractors, loaders or similar equipment?

Any use of chippers, mulchers, cherry pickers, booms or other similar equipment


Any use of pesticides or fertilizers?

of 9Tangram Insurance Services, Inc.If yes, is the application completed by:

Any boulder or tree removal performed?

Any highway or median work conducted?

Employee? Outside Vendor?


NoYes

NoYes

NoYes

Yes No NoYes

NoYes

Yes No

NoYes

Yes No

Yes No

NoYes

NoYes

NoYes

NoYes

Yes NoAny debris removal or land clearing activities?


Manufacturing - Machine Shops

Any punch press or press brake machinery/equipment?

Age of machinery:

Types of machines (must equal 100%):

% of off-premises operations:

Machine Guarded:

Accessible moving parts guarded on machinery/equipment?

Any Computer Network Controlled (CNC) machinery?

Drive MechanismPoint of Operation

<2 yrs 2-5 yrs 5-10 yrs 10+ yrs

Heavy: Mid: Light:

If yes, where/what for?

Is building properly ventilated? Is proper dust collection system in place?

Restaurants

Entertainment provided?

Fast food?

Number of:

Bar or separate lounge area?

Any catering?

If yes, radius of operations:

Any delivery?

Average price of entree?

Servicing, cleaning of hoods/.filters/grease traps or related systems provided by:

miles % of exposure:

miles % of exposure:If yes, radius of operations:

Hosts Waitpersons Bartenders

Valets Busboys Cooks

$15+$5-$15<$5

Outside Vendor Employees

Retail / Wholesale

Type of Merchandise?

Gross Receipts: Wholesale

Any repacking or repacking operations?

If yes, please explain operations:

Assembly exposure?

Any distribution exposure?

% Retail % Warehousing?

If yes, please explain exposure:

If yes, by common carrier or does insured have a trucking exposure? Please explain on a separate page.

Trucking

Type of Authority: a)

b)

Common Carrier Contract Carrier Private Brokerage Exempt

Irregular RouteRegular Route

Carrier Operations: California Only Interstate

Length of Haul with Total % = 100% Under 50 Miles

301 - 500

50 - 200

501 - 1,000

201 - 300

Over 1,000

%

%

%

%

%

%

Filings: DOT# PUC# DMV/MCP# Not Applicable

Please Check the Questions and Attach the Applicable Data:

Motor Carrier Identification Report, MCS-150: Not ApplicableAttached or

Cargo Classification: See attached MCS-150 or See below (check all that apply):

General Freight

Household Goods

Metal Sheets, Coils, Rolls

Motor Vehicles

Driveway / Towaway

Other

Fresh Produce

Machinery, Large Objects

Mobile Homes

Building Materials

Logs, Poles, Beams, Lumber

Livestock

Oilfield Equipment

Passengers

Intermodal Containers

Liquids/Gases

U.S. Mail

Garbage, Refuse, Trash

Meat

Coal, Coke

Grain, Feed, Hay

Paper Products

Beverages

Refrigerated Food

Commodities Dry Bullion

Chemicals



Drivers:

a) Number of Drivers

b) Number of Owner/Operators used

- Percentage where the Motor Carrier will provide workers compensation for Owner/Operators

- Percentage where the Motor Carrier will agree with the Owner/Operator that the Owner/Operator assumes the responsibilities of an Employer for the performance of work:

c) If Onwer/Operator used, please attached copy of contract:

d) Number of company drivers with Motor Carrier at least 12 months:

Number of Owner/Operators with Motor Carrier at least 12 months:

e) Number of Non Union:

f) Do the drivers load and unload their trucks?

Is the applicant enrolled in the DMV Pull Program?

Any trucks / trailers with ramps?

Is the applicant enrolled in the CHP BIT Program?

Total # of Trucks:

%

%

Attached or Not Applicable

Not Applicableor

Union:

NoYes

Yes No

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

No Yes (please provide detail of the types of materials loaded/unloaded and any equipment used):

Any trucks / trailers with lift-gates?

Any team driver operations?

If union operations, please provide Month / Year of contract renewal:

If so , how often:

# of Trucks with Sleeper Cabs: Single Trailers: Double Trailers: Triple Trailers:

If yes, please provide #:

If yes, please provide #:


Public Entities

Municipality: County:

Check each applicable operational department / category:

Fire Department

Public Housing Nurse

Landscape Maintenance

Street Sweeping/Cleaning

Truck Driver

Day Care/Child Care

Parks/Recreation

Street / Road Department

Mechanic

Housing Authority

Garbage/Refuse/Recycling

Sewer DepartmentPower Department

Code Enforcement

Waste Treatment

Painters

Animal ControlPolice Department

Electricians

Tree Trimming

Building Inspector

Water Department

# P/T Staff:# F/T Staff:

Any Volunteers or Intern Staff?

City Council Positions?

County Supervisor Positions?

Does the hiring process include: Drug Screening?

Any Post Accident Drug Testing?

Is there are probationary period upon hire?

Are employees provided with any New Employee Orientation?

Does each job have a written job description?

Do employees receive initial job training?

Is training on-going and documented?

Do employees work shifts?

Any on call employees?




If yes, please explain: of 9Tangram Insurance Services, Inc.

#

#

Pre Employment Physicals? If yes, please explain:


Do any employees have take home vehicles?

Any underground work?

Any work above 12' in height?

Any confined space exposures?

If yes, is there a Written Confined Space Entry Program?

Any sub-contracted operations?

Any W/C Certificates of Insurance obtained on all sub-contractors?

Any use of independent contractors?

Number of vehicles?

Do employees use personal vehicles for business purposes?

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No

NoYes

NoYes

Yes No

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No If yes, please explain:







Driving Radius?

Newspaper / Publishing

Any home delivery service?

Provide details:

Any delivery operations?

Any telemarketing operations?

Provide details:

Any security operations?

Provide details:

Do employees or independent contractors use personal vehicle for company business?

If yes, are certificates of insurance on file?

Are MVR's (Motor Vehicle Reports) obtained for all drivers?

Any employee or independent contractor travel: Out of State, Out of Country, On Navigable Waters, within War Zones or Exposure to Civil Disturbances, etc:


Any excessive noise level testing has been completed, within the Press / Bindery Areas and/or areas with noise producing machinery and equipment?

Any excessive noise levels within the operations?

If noise level testing has been completed, are copies of the results available for review?

Does the company have a written Hearing Conservation Program?

Do employees use/wear and PPE (Personal Protective Equipment)

Does the company have a written Ergonomics Program?

Does the company have a written Material Handling Program, with identified weight limits?

Does the company have written Lock Out/Tag Out Program?



Is maintenance of equipment/machinery completed by employees and/or outside vendors?

Are all forklift/material handling equipment operations certified?

If yes, independent contractors and/or employees?

If yes, # of vehicles: Driving Radius?

If yes, independent contractors and/or employees?

If yes, independent contractors and/or employees? Unarmed?Armed? or

Is the company enrolled in a DMV "Pull" Program?

If yes, provide details:

If yes, provide details:



Pest Control

CommercialType of operations: Agricultural Residential Industrial Structural Structural Repairs or replacements

Chemical Treatment ServicesOtherFoamFumigationDry Rot Wood Repair

Shower Pan Replacement

Provide details:

Percentage of Tenting, if any:

Lawn Treatment or Care?

Other Service:

Provide details:

Mark each of the applicable services available:

TicksFleasRoachesSpidersAnts Wasps

Mosquitoes Bees Killer Bees Bee Removal Mice Termites

Rats Snakes Raccoons Opossum Skunks Bats

Rodents Gopher Control Bird/Pigeon Control Animal Trapping Animal Removal Bird/Rodent Proofing

Other, please provide details:

Personal Protective Equipment Required:

Written Injury & Illness Prevention Program?

Written Heat Stress Program?

Written Fall Protection Program?

Special Written Procedures for working in Confined Spaces (Attics & Under Residences / Buildings)?

Documented New Employee Orientation including Documented Training?

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

Yes No If yes, provide details:

Written Haz-Com Program?

Written Respiratory Protection Program?

Note: All information provided is subject to verification by way of an underwriting survey or inspection. Tangram Insurance Services, Inc. must be notified of any significant changes in operations or payroll. Terms of insurance coverage may be cancelled for misrepresentation if information provided is inaccurate.

Signature of Applicant: Date:

workers compensation supplemental application business_wc_supplemental_applic… · workers...

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