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Please check "Y" or "N" for each question! |
Y |
N |
Please check "Y" or "N" for each question! |
Y |
N |
Have you had any OSHA violations in the past five (5) years?
If YES, please explain below:
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Is entity subject to Jones Act?
If YES, please explain below:
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Have you filed bankruptcy in the last five (5) years?
If YES, please explain below:
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Is entity subject to Federal Employer's Liability Acgt?
If YES, please explain below:
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Do you own, lease, or charter aircraft or watercraft?
If YES, please explain below:
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Is entity subject to U.S. Longshore & Harbor Act?
If YES, please explain below:
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Do you have, or comtemplate having, any employees under the age of 18?
If YES, please explain below:
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Underground / tunneling or sub-aqueous work?
If YES, please explain below:
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Do you have, or comtemplate having, any employees over the age of 65?
If YES, please explain below:
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Are employee's healthcare plans covered?
If YES, please explain below:
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Do you use any leased or temporary employees?
If YES, please explain below:
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Are all forklift operators certified?
If YES, please explain below:
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Height exposure? Max:
feet
If applicant performs work at heights over 15 ft., please explain below:
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Maximum weight of material that is MANUALLY being handled? |
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Do you use sub-contractors?
Please explain all "Yes" answers below:
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Does the entity handle, store, or transport any explosive, caustic?
If YES, please explain below:
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Has this applicant (or affiliate) been in the Texas Workers' Compensation System in the last 3 years?
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Has the applicant (or affiliate) ever had an Occupational Disease (e.g. Black Lung, silicosis, lead poisoning, cancer, etc.) or Cumulative Trauma (e.g. carpal tunnel, stress, etc.) claim?
If YES, please explain below:
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Has applicant (or affiliate) ever had an Employer's Liability Claim?
If YES, please explain below:
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Do you have any out of state operations (i.e. temporary assignments, routine travel, transporation)?
If YES, please explain below:
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Do you have underground exposure in excess of 6 feet? If YES, feet
If YES, please explain below:
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Does the applicant have Employer's Excess Indemnity Coverage?
If YES, please give Carrier name:
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