ࡱ> q` bjbjqPqP .::""""D"Fhh$h$h$h$h$G%G%G%uFwFwFwFwFwFwF$^HhJFG%C%G%G%G%Fh$h$F'''G%8h$h$uF'G%uF''>}@h$\$ *^S"W%L?@F0F?LK%LK4}@LK}@4G%G%'G%G%G%G%G%FF' G%G%G%FG%G%G%G%"" CustomComp Process Workers Compensation Insurance Questionnaire Applicant Information Name / Phone Number / FEIN / Year Business Started / Business/Contractors License # Location Addresses: 1. 2.  Description of Operations  Rating Information  # EmployeesStateLocation NumberClass Code CATEGORIES, DUTIES, CLASSIFICATIONFull TimePart TimeAnnual PayrollCA1               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. Any tax liens or bankruptcy in the past 5 years? Please provide the following data for the past 5 years of Workers Comp Insurance Policies: Current Insurance Company Expiration Date # of Years Insured w/ Current Insurance Company Policy # Prior Insurance Company Expiration Date # of Years with Prior Carrier Prior Policy # Please provide this same information for additional insurance companies in remarks. 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