ࡱ> EGBCDq` 3bjbjqPqP .n::+bbbb\\\\|]lzh~a~a~a~a~a]b]b]b$hJ0cYb]b0c0cbb~a~a4bebebe0c4b8~a~abe0cbebeuuuv~ara pO\dcvvLJ0zv\ЍcfЍ(uvЍuv8]b0b"bebbe]b]b]bRe]b]b]bz0c0c0c0cU\\bbbbbb BUSINESS INSURANCE QUESTIONNAIRE Applicant Information Business NameMailing Address / Phone # / FEIN / CA Tax ID / Year Business Started / / Description of Operations: Prior Coverage Provide Complete Information for Past 5 Years ( General Liability ( Property ( Automobile ( Workers Comp ( Other Insurance Co. Expiration Date # of Years with Prior Carrier Prior Policy # ( General Liability ( Property ( Automobile ( Workers Comp ( Other Insurance Co. Expiration Date # of Years with Prior Carrier Prior Policy # Physical Location #1 Information ( Own ( Rent Address Type of ConstructionImprovements: Year When UpdatedYear BuiltWiringSquare FootagePlumbingRoof Type & AgeHeatingBuilding Insurable Value$Leasehold Improvements$Contents Insurable Value$Computers Insurable Value$ Physical Location #2 Information ( Own ( Rent AddressType of ConstructionImprovements: Year When UpdatedYear BuiltWiringSquare FootagePlumbingRoof Type & AgeHeatingBuilding Insurable Value$Leasehold Improvements $Contents Insurable Value$Computers Insurable Value$Please reproduce this page for additional locations. GENERAL LIABILITY Limits Rating Basis ( 500,000 Annual Payroll $___ ( 1,000,000 Annual Revenue $____________ ( 2,000,000 Total # of Employees: ____________ General Information Explain all Yes responses in the Remarks space provided below. ( Yes ( No1. Any medical facilities provided or medical professionals employed or contracted?( Yes ( No2. Any exposure to radioactive/nuclear materials?( Yes ( No3. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)( Yes ( No4. Any operations sold, acquired, or discontinued in last 5 years?( Yes ( No5. Machinery or equipment loaned or rented to others?( Yes ( No6. Any aircraft, watercraft, docks, floats owned, operated, hired or leased?( Yes ( No7. Any parking facilities owned/rented?( Yes ( No8. Is a fee charged for parking?( Yes ( No9. Recreation facilities provided?( Yes ( No10. Is there a swimming pool on the premises?( Yes ( No11. Any athletic activities, sporting or social events sponsored?( Yes ( No12. Any structural alterations contemplated?( Yes ( No13. Any demolition exposure contemplated?( Yes ( No14. Has applicant been active in or is currently active in joint ventures?( Yes ( No15. Do you lease employees to or from other employers?( Yes ( No16. Is there a labor interchange with any other business or subsidiaries?( Yes ( No17. Are day care facilities operated or controlled?( Yes ( No18. Have any crimes occurred or been attempted on your premises within the last 3 years?( Yes ( No19. Is there a formal written safety and security policy in effect?( Yes ( No20. Does the businesses promotional literature make any representations about the safety or security of the premises? Remarks___________________________________________________________________________________________________________________________________________________________________________________________________________ Additional Insured Information List any entities, such as mortgage holder, landlord, for which proof of insurance must be provided. Description of InterestAdditional Insureds Name and Mailing AddressAdditional Insureds Fax # Excess Liability (aka: Umbrella) Insurance Desired? ( Yes ( No: If yes, what limits? $__________________ BUSINESS AUTO INFORMATION Driver Information List all drivers. Drivers Legal Name  SexDate of BirthDrivers License Number & StateSocial Security Number Accidents/Convictions Has any driver shown above had an accident regardless of fault, or been convicted of a moving violation with the last 3 years? ( Yes ( No If yes, answer the following questions for each accident/conviction DriverDate of Accident/ Conviction Description of Accident/Conviction Place of Accident/Conviction Bodily Injury or Death? Dollar Amount of Property Damage Vehicle Information Total Numbers of Vehicles ___________ If necessary, please copy this page to complete following section for all vehicles or attach your spreadsheet providing all the information requested below for each vehicle. Vehicle 1Vehicle 2Vehicle 3Vehicle 4Vehicle 5YearMakeModelBody TypeVehicle ID #Registered StateCost NewDescription of UseRadius of Operation( 0-50 mi. ( 51-200 mi. ( Over 200 mi.( 0-50 mi. ( 51-200 mi. ( Over 200 mi.( 0-50 mi. ( 51-200 mi. ( Over 200 mi.( 0-50 mi. ( 51-200 mi. ( Over 200 mi.( 0-50 mi. ( 51-200 mi. ( Over 200 mi.Physical Damage Coverage?( Yes ( No( Yes ( No( Yes ( No( Yes ( No( Yes ( NoLienholders Name And Address REMARKS: ________________________________________________________________________ __________________________________________________________________________________ Auto Limits to be Quoted Liability ( $300,000 ( $500,000 ( $1,000,000 Personal Injury Protection (per person) ( $2,500 ( $5,000 ( $10,000 Uninsured/Underinsured Motorists ( Same as Liability ( Other ________________________ Hired Auto Liability* ( None ( $1,000,000 ( Other ________________________ Non-Owned Auto Liability* ( None ( $1,000,000 ( Other ________________________ *Hired Auto Liability provides liability coverage for vehicles you rent or hire. Non-Owned Auto Liability provides liability coverage for your business when your employee uses their personal auto for your business. General Information Provide explanation for all Yes responses ( Yes ( NoWith the exception of any encumbrances, are any vehicles not solely owned by and registered to the insured?( Yes ( NoDo over 50% of the employees use their autos in the business?( Yes ( NoIS there a vehicle maintenance program in operation?( Yes ( NoAre any vehicles leased to others?( Yes ( NoAre any vehicles customized, altered or have special equipment?( Yes ( NoAre ICC, PUC or other filings required?( Yes ( NoDo operations involve transporting hazardous material?( Yes ( NoAny hold harmless agreements?( Yes ( NoAny vehicles used by family members? If so, identify in Remarks.( Yes ( NoDoes the applicant obtain MVR verifications?( Yes ( NoDoes the applicant have a specific driver recruiting method?( Yes ( NoAre any drivers not covered by workers compensation?( Yes ( NoAny vehicles owned but not scheduled on this application?( Yes ( NoAny drivers with moving traffic violations? Lienholder Information Vehicle No.Lienholder Name and Mailing AddressLoan Number WORKERS COMPENSATION INFORMATION Locations #STREET, CITY, COUNTY, STATE, ZIP CODE123Rating Information # EMPLOYEESSTATELOC # (above)CLASS CODE CATEGORIES, DUTIES, CLASSIFICATIONFULL TIMEPART TIMEANNUAL PAYROLL 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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