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)
Not
