Workers' Compensation Insurance Request for Proposal

Firm Name :                     
Contact Name:                                          [return home]
Address:                           
City:                                      State:    Zip:
Phone:                                   Fax: 
Years in Business:             
Type of Business:              
Federal Employer ID #      

Locations:

#

Street, City, State, Zip Code

 #

Street, City, State, Zip Code

1 6
2 7
3 8
4 9
5 10

Proposed Effective Date:

Rating Information:

Class Code Categories Payroll # of Employees

Individuals Included/Excluded: Partners/Officers/Relatives

Name DOB Title/Relationship Ownership % Duties Incl./Excl. Salary

General Information:

Explain All "Yes" in "Remarks Below

  
1.  Does Applicant Own, Operate or Lease Aircraft or Watercraft?
2.  Do/Have Past, Present or Discontinued Operations Involve(d) Storing, Treating, Discharging, Applying, Disposing, Or Transporting of Hazardous Materials? (e.g. landfills, waste, fuel tanks, etc.)
3.  Any Work Performed Underground or Above 15 feet?
4.  Any Work Performed on Barges, Vessels, Docks, Bridge Over Water?
5.  Is Applicant Engaged in Any Other Type of Business?
6.  Are Sub-Contractors Used?  If Yes, Give % of Work Subcontracted
7.  Any Work Sublet Without Certificates of Ins.?
8.  Is A Formal Safety Program in Operation?
9.  Any Group Transportation Provided?
10. Any Employees Under 16 or over 60 years of Age?
11. Any Seasonal Employees?
12. Is there Any Volunteer or Donated Labor?
13.Any Employees with Physical Handicaps?
14. Do Employees Travel Out of State?
15. Are there Athletic Teams Sponsored?
16. Are Physicals Required After Offers of Employment are Made? 
17. Any Other Insurance With this Insurer?
18. Any Prior Coverage Declined, Canceled, Or Non-Renewed (last 3 years)? Not Applicable in Month
19. Are Employee Health Plans Provided?
20. Is There a Labor Interchange with Any Other Business/Subsidiary?
21. Do You Lease Employees to Or From Other Employers?
22. Do Any Employees Predominantly Work At Home? 

Remarks:

Applicable In Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud, penalties include imprisonment, fines and denial of insurance benefits 

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties

Any claims in the past 4 years?: