Workers Compensation Form Name Business Is --Select--INDVPARTNERCORP Describe Business DBA Phone Insured's Name FEIN NO Polycy Eff no Location Address Mailing Address No. of Employees Full Time Part Time Number of Active Partners Anual Payroll Gross Income Years Of Business Prior Carrier Policy Group Helth Insurance --Select--YesNo Insurance Company Number of officers INCLUDING OFFICERS IN WORKERS COMP. YES --Select--YesNo NAME AND PERCENTAGE OF SHAREHOLDER ANY SEASONAL OR HANDICAP OR OVER 60 YEARS OR UNDER 16 YEARS OLD EMPLOYEE --Select--YesNo DO EMPLOYEES TRAVEL OUT OF STATE OR WORK PREMONITORY AT HOME --Select--YesNo ARE SUB-CONTRACTORS USE YES NOT IF YES HOW MANY % --Select--YesNo ARE SUB-CONTRACTORS USE YES NOT IF YES HOW MANY % LASR 3 YEARS? --Select--YesNo IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS --Select--YesNo INSURED HISTORY: Years in business: No. of locations Description of operations Hours of operation: No. of daily shifts: Number of employees: Full-time Part-time Seasonal Volunteers Percent of employee turnover in the last 12 months Full-time Part-time Employee staffing expectation over the next 12 months Full-time Part-time Average hourly wage: Full-time $ Part-time $ Benefits provided – are ALL employees eligible --Select--YesNo If not then who is eligible? _ Group Health --Select--YesNo % paid by employer % of participation Paid sick leave --Select--YesNo % paid by employer % of participation Vacation --Select--YesNo % paid by employer % of participation Retirement / Pension Plan --Select--YesNo % paid by employer % of participation Indicate the safety activities currently established and practiced regularly: Safety program / IIPP in use compliant with California SB 198 --Select--YesNo Return to light duty plan --Select--YesNo Includes full wages --Select--YesNo Return to Full-time modified work plan --Select--YesNo Designated Full-time safety director --Select--YesNo Name Safety meetings held for all employees --Select--YesNo Frequency of meetings Safety training held for all employees --Select--YesNo Incentive program for employees --Select--YesNo Personal protective safety equipment provided for all employees --Select--YesNo CPR training provided --Select--YesNo Supervisors are held accountable for injuries / accidents --Select--YesNo Accident investigation program in place --Select--YesNo HIRING PRACTICES: Employment application --Select--YesNo Drug/substance abuse --Select--YesNo Reference checks --Select--YesNo Audiometric testing --Select--YesNo Motor Vehicle Record check --Select--YesNo Pre/Post employment physical --Select--YesNo Volunteer labor used --Select--YesNo Pathogenic test (i.e. lead) --Select--YesNo Temporary labor used --Select--YesNo Orthopedic back test --Select--YesNo AUTOMOBILES: Business Operations include driving by employees for the following purpose(s): Delivery --Select--YesNo Frequency of delivery: --Select--DailyWeeklyOther Delivery radius: --Select--< 50 miles51-100 miles101-250 miles>250 miles Travel to or Between Jobsites/Facility Locations --Select--YesNo If yes: Frequency: Radius Is there any group transportation of employees? --Select--YesNo If yes, indicate max # employees per vehicle: Sales/Service Calls --Select--YesNo If yes: Frequency: Radius # of authorized drivers # of company vehicles #of employee-owned vehicles used in business Frequency of MVR checks Participation in CHP Pull program --Select--YesNo Driver acceptability standards have been established --Select--YesNo Frequency Vehicles inspection / maintenance program --Select--YesNo Frequency Vehicle maintenance is performed by employees --Select--YesNo Frequency Employees take company vehicles home at night --Select--YesNo Frequency PAYROLL AND PREMIUM HISTORY: Payroll : Current Yr 1st Prior Yr 2nd Prior Yr. 3rd Prior Yr. Premium: Current Yr. 1st Prior Yr. 2nd Prior Yr. 3rd Prior Yr. Job Duties & Description Class Code Estimated Payroll # Full Time # Part Time The above information is true to the best of my knowledge. I authorize Insure Pal Insurance Services the use of the above information for the purpose of obtaining a quotation for insurance. I also understand by submitting this information does not mean that I have purchased an insurance policy. This information is used only to provide a quote.
