ࡱ> ` Pbjbjss .Mlll!!!!T\!Ch######V9$$]$xCzCzCzCzCzCzC$aEhGCl%##%%C##C%%%%8#l#xC%%xC%%r;Tl<#" Y !:%X*<=C0CB<OH%LOH0<<&OHl=q$"$%$$_q$q$q$CC%q$q$q$C%%%%d d  Apartment Owners Workers Compensation Insurance Questionnaire Applicant Information Effective Date:_________ Name: DBA (if any):  (corporation, ( LLC, ( LLP (partnership, (IndividualMailing Address Phone / Fax / Email / /FEIN / CA Tax ID / Year Business Started / / Please Provide a Detailed Description of Operations:  WORKERS COMPENSATION INFORMATION Locations #STREET, CITY, COUNTY, STATE, ZIP CODE12 Rating Information # EMPLOYEESSTATELOC # (above)CLASS CODE CATEGORIES, DUTIES, CLASSIFICATIONFULL TIMEPART TIMEANNUAL PAYROLLApartment Owners General Information Explain all Yes responses in the Remarks space provided below. ( Yes ( No1. Do you perform any work underground or above 15 feet? ( Yes ( No2. Is any work performed on barges, vessels, docks, bridge over water?( Yes ( No3. Are you engaged in any other type of business? ( Yes ( No4. Are sub-contractors used? If yes, give % of and type of work subcontracted:( Yes ( No5. Any work sublet without certificates of insurance?( Yes ( No6. Is a written safety program written and in operation, in compliance with SB198? Other programs?( Yes ( No7. Is there a Safety Incentive Award program in place?( Yes ( No8. Are there any employees under 16 or over 60 years of age?( Yes ( No9. Are there any seasonal employees?( Yes ( No10. Is there any volunteer or donated labor?( Yes ( No11. Are there any employees with physical handicaps?( Yes ( No12. Do you require physicals after offers of employment are made?( Yes ( No13. Do you have a written Modified or Return to Work Program for employees returning after an injury? ( Yes ( No14. Do you offer any employee health plans? If so, what percentage of employees participate? %( Yes ( No15. Are employee health plans ( ) paid by the employer or ( ) do employees participate in the cost?( Yes ( No16. Company Benefits include: ( ) Vacation Leave? ( )Sick Leave? ( )Paid Time Off? ( Yes ( No17. Do any employees predominantly work at home?( Yes ( No18. Do you lease employees to or from other employers?( Yes ( No19. Is there a labor interchange with any other business/subsidiary?( Yes ( No20. Do or have past, present, or discontinued operations involved storage, treating, or handling of hazardous materials?( Yes ( No21. Do employees work with Hazardous Materials known to be toxic or carcinogenic?( Yes ( No22. Do you provide transportation for employees?( Yes ( No23. Do you provide vehicles for employees?( Yes ( No24. Do any of your employees drive your or their own vehicles as a part of their work?( Yes ( No25. Do you check driving records for those employees driving on your behalf?( Yes ( No26. Do any employees travel out of state?( Yes ( No27. Do any employees travel out of the country? ( Yes ( No28. Do you own, operate, or lease aircraft? Watercraft?( Yes ( No29. Has prior coverage been declined, cancelled, or non-renewed in the past 3 years?( Yes ( No30. Has your Workers Compensation Insurance been canceled for non-report of payroll?( Yes ( No31. Is your current insurance company requesting to be replaced?( Yes ( No32. Has your Workers Compensation Insurance been permitted to lapse for over 90 days?( Yes ( No33. Do you have a full-time Human Resources manager? ( Yes ( No34. Are the Owners active in the business?( Yes ( No35. 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