Person Completing this application

Name

Phone

E Mail

1

Legal Name of Business

2

Name of Insured /Owner

3

Exact Location Address

How long at this Location ?

4

Additional Locations

(use separate sheet for each location to be Insured)

5

Exact Nature of Business

Please be specific with details for each location.

6

Contact Person for Questions regarding this Application, Audit and Inspection

7

E mail

8

Fax Number

9

     Phone Number

10

Web Site Address / URL

11

Date you started this business

Number of years in Business

12

Federal Tax ID #

State Tax ID #

13

Number of F/ T  Employee’s

Number of P/T Employee’s

14

Annual Payroll

$

Annual or Projected Gross Sales

$

15

Any Claims in the Last 3 yrs?

Y

N

If yes, the amount of loss $  

16

Loss Runs for the last 3 years are required

17

Hours of Operation

Open at

 Close at

18

Present Workers Compensation Carrier

19

(Circle) Liability coverage Limit

$ 1,000,000    or      $ 5,000,000     or  Other :

Would you like a competitive quotes for the following:

20

Errors and Omission (E&O) Coverage?

Y

N

Directors and Officers ( D&O ) Coverage?

Y

N

21

Commercial General Liability

Y

N

Health Insurance

Y

N

Additional Comments:

Workers Compensation Insurance Application Section

YES

NO

22

Does applicant own, operate or lease aircraft/watercraft?

23

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)

24

Any work performed underground or above 15 feet?

25

Any work performed on barges, vessels, docks, bridge over water?

26

Is applicant engaged in any other type of business?

27

Are sub-contractors used? (If yes, give % of work subcontracted)

28

Any work sublet without certificates of ins.?

29

Is a written safety program in operation?

30

Any group transportation provided?

31

Any employees under 16 or over 60 years of age?

32

Any seasonal employees?

33

Is there any volunteer or donated labor?

34

Any employees with physical handicaps?

35

Do employees travel out of state?

36

Are athletic teams sponsored?

37

Are physicals required after offers of employment are made?

38

Any prior coverage declined/canceled/non-renewed (last 4 years)

39

Are employee health plans provided?

40

Is there a labor interchange with an other business/subsidiary?

41

Do you lease employees to or form other employers ?

42

Do any employees predominantly work at home?

43

Any tax liens or bankruptcy within the last 5 years?

44

Inspection Contact:

45

Accounting Record Contact:

46

Claims Info Contact:

State Compensation Insurance Fund Supplemental Insurance Application

YES

NO

47

Was this operation all or part of an existing business that was purchased on acquired? (If yes, also complete Section 7.)

48

Has any principal of the business declared bankruptcy in the last seven years? (If yes, also complete Section 8)

49

Received any OSHA citations within the past year?

50

Employ any relatives?

51

Employ any minors? (Under age 18)

52

Make any cash payments to employees or subcontractors?

53

Provide meals or lodging in lieu of wages?

54

Pay any employees by the piece?

55

Have any operations outside of California?

56

Have any work at a maritime or offshore facility?

57

Perform any asbestos removal?

58

Use any equipment that bends, forms, shapes, or cuts materials (e.g., power press)?

59

Have any locations/operations for which coverage is not requested?

60

Have a written return-to-work program for employees injured on the job?

61

Have a minimum of 3 employees?

62

   of employees eligible* for health insurance? (*Eligible employees are those who work a minimum of 30 hours per week.)

63

Majority of employees eligible* for health insurance? (*Eligible employees are those who work a minimum of 30 hours per week.)

64

Employer pays more than 50% of health insurance premium for eligible employees?

65

Member of any trade or business association?

Please indicate:

Remarks for all Yes answers Question # 1 to Question 70

Please give details, use additional pages if needed

Q #

Response, Remarks for Yes answers, please be specific and give details of all questions that were answered YES

Total #  of Employees

in each State & each Classification

Classification / Job Description

Full Time

Part Time

Total Payroll last 12 months

Total Payroll projected next 12 Months

Total

$

$