WORKERS COMPENSATION INSURANCE

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

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

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

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

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 : Current Yr

1st Prior Yr

2nd Prior Yr.

3rd Prior Yr.

Premium: Current Yr.

1st Prior Yr.

2nd Prior Yr.

3rd Prior Yr.

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.