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Workers Compensation Supplemental Business_WC_Supplemental_Applic · PDF fileWorkers Compensation Supplemental Application (To be Completed with Acord 130 application) Named Insured:

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  • 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. Page 1 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?

    If yes, please provide details:

    RTW Program?

    Does it include salary continuance?

    Hiring Practices - Employee Section - Claims

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

    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?

    Page 2 of 9Tangram Insurance Services, Inc.

    If yes, please explain: Another business Subsidiary

    between departments Other:

    If yes, please provide explanation on separate page.

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

    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,

  • 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".)

    Page 4 of 9Tangram Insurance Services, Inc.

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

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