Does applicant own, operate or lease aircraft/watercraft?
Yes
No
Do/Have past, present or discontinued operations involve(d), storing, treating, discharging, applying, disposing or transporting of hazardous material?
Yes
No
Any work performed underground or above 15 feet?
Yes
No
Any work performed on barges, vessels, docks, bridges over water?
Yes
No
Is applicant engaged in any other type of business?
Yes
No
Are sub-contractors used?
Yes
No
Any work sublet without certificates of insurance?
Yes
No
If yes, payroll for this work must be included in the rating information
Is a written safety program in operation?
Yes
No
Any group transportation provided?
Yes
No
Any employees under 16 or over 60 years of age?
Yes
No
Any seasonal employees?
Yes
No
Is there any volunteer or donated labor?
Yes
No
Any Employees with Physical handicaps?
Yes
No
Do Employees travel out of state?
Yes
No
Are atheltic teams sponsored?
Yes
No
Are physicals required after offers of employment are made?
Yes
No
Any other insurance with this insurer?
Yes
No
Any prior coverage declined/cancelled/non-renewed in the last three years?
Yes
No
Are employee health plans provided?
Yes
No
Do any employees perform work for other businesses or subsidiaries?
Yes
No
Do you lease employees to or from other employers?
Yes
No
Do any employees predominately work at home?
Yes
No
Any tax liens or bankruptcy within the last 5 years?
Yes
No
Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises?
Yes
No
has the insured had any lapse in workers compensation coverage?
Yes
No
Have employees been working without workers compensation coverage?
Yes
No
Is the insured aware of any claims/losses in the last 4 years?
Yes
No
Any work or locations outside of the state (mailing address state)?
Yes
No
Any employees travel over 200 miles?
Yes
No
Is this a newly established business?
Yes
No