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Workers Compensation
Questionnaire |
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1. Does applicant own, operate or lease
aircraft/watercraft? |
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2. 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) |
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3. Any work performed underground or
above 15 feet? |
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4. Any work performed on barges,
vessels, docks, bridge over water? |
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5. Is applicant engaged in any other
type of business? |
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If yes, please list
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6. Are sub-contractors used? |
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If yes, give % of work
subcontracted
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7. Any work sublet without certificates
of ins.? |
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8. Is a written safety program in
operation? |
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9. Any group transportation provide? |
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10. Any employees under 16 or over 60
years of age? |
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11. Any seasonal employees? |
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12. Is there any volunteer or donated
labor? |
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13. Any employees with physical
handicaps? |
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14. Do employees travel out of state? |
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15. Are athletic teams sponsored? |
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16. Are physicals required after offers
of employment are made? |
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17. Any prior coverage declined/cancelled/non-renewed
(last 3 years)? |
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18. Are employee health plans provided? |
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19. Is there a labor interchange with
any other business/subsidiary? |
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20. Do you lease employees to or from
other employers? |
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21. Do any employees predominately work
at home? |
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22. Any tax liens or bankruptcy within
the last 5 years? |
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23. Any undisputed and unpaid workers compensation
premium due from you or any commonly managed or owned enterprises? |
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If yes, explain including
entity name(s) and policy number(s)
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Please describe
your business: |
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