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YES |
NO |
| 1. Does applicant own, operate or lease air/water craft? |
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| 2.
Do/have past, present or discontinued operations involve(d) storing,
treated, 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 or bridges over water? |
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| 5. Is applicant engaged in any other type of business? |
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| 6. Are subcontractors used? (If yes, give % of work subcontracted
%) |
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| 7. Any work sublet without certificates of insurance? |
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| 8. Is a written safety program in operation? |
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| 9. Any group transportation provided? |
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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 any employees travel out of state? |
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| 15. Are any athletic teams sponsored? |
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| 16. Are physicals required after offers of employment are made? |
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| 17. Any other insurance with this insurer? |
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| 18. Any prior coverage declined/cancelled/non-renewed within past 3 years? |
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| 19. Are employee health plans provided? |
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| 20. Is there any interchange of labor? |
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| 21. Do you lease employees to or from other employers? |
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| 22. Do any employees predominately work from home? |
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| 23. Any tax liens or bankruptcy within the last 5 years? |
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24.
Any undisputed and unpaid workers compensation premium due from you or
any commonly managed or owned enterprises? If yes explain including
entity name(s) and policy number(s). |
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