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IMPORTANT INSTRUCTIONS for using this form Please note REQUIRED fields (all YELLOW) on this form as follows:   Text Boxes - All yellow are required   Radio Buttons - Must select at least one item as required   Check Boxes - Must select at least one item as required     White Boxes/Buttons - Not Required fields

 

Do you have? Please check below:   Life & Health License   Property & Casualty License   E & O Coverage Type of Proposal Requested:   Occ Acc WITHOUT Employer's Legal Liability   Occ Acc WITH Employer's Legal Liability   Stand Alone Employer's Excess Indemnity

Applicant Information Requested Effective Date:    Business Name and dba:  Physical Address:  City:  State:  Zip: Click Here if Mailing Address is same as Physical Address.  Mailing Address:    City:  State:  Zip:    Corporation    Partnership    Sole Proprietorship    LLC    Other:    Yrs in Business:  Phone:  Fax:  Website:  Federal Tax ID #:  No. of Locations:  Hrs. of Operations:   Are any affiliate companies to be covered?   Yes    No  If YES, please provide legal name, address, number of employees, and Tax I.D. #'s below:    Contact Name:  Title:  e-Mail:  Details of Operations:    Has Workers' Comp or Occupational Accident Coverage ever been cancelled, refused, or non-renewed?    Yes    No  If YES, please explain:  Date of Workers' Comp Coverage Rejection:

Rating Information # of Full-Time # of Part-Time  Classification Code  Annual Payroll (Including tips, bonus, commission) Classification or Description EMP (W2) Contract Labor (1099) EMP (W2) Contract Labor (1099) $ $ $ $ $ $ $ $  Officers/Owners/Partners:  Included    Excluded

Loss Information for current/prior 3 yrs  (All losses must be first dollar losses) Valuation Date:   Period Carrier Medical Pd. Indemnity Pd. Reserved Total Inc. # of Losses (Total) # of Losses $5K or Over Premium 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 > 20 0 1 2 3 4 5 > 05  Please give a detailed discription for each loss of $5,000 or greater:  Loss #1:   Loss #2:   Loss #3:   Loss #4:   Loss #5:   All  Others:  0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 > 20 0 1 2 3 4 5 > 05  Please give a detailed discription for each loss of $5,000 or greater:  Loss #1:   Loss #2:   Loss #3:   Loss #4:   Loss #5:   All  Others:  0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 > 20 0 1 2 3 4 5 > 05  Please give a detailed discription for each loss of $5,000 or greater:  Loss #1:   Loss #2:   Loss #3:   Loss #4:   Loss #5:   All  Others:  0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 > 20 0 1 2 3 4 5 > 05  Please give a detailed discription for each loss of $5,000 or greater:  Loss #1:   Loss #2:   Loss #3:   Loss #4:   Loss #5:   All  Others:

Safety Exposure Please check "Y" or "N" for each question! Y N Please check "Y" or "N" for each question! Y N  Does entity have a formal maintenance/  Safety program?  When was it last updated?  Is there an appointed Safety Director?    Safety Director's Name:  Written Safety Manual?  Safety Committee?  Safety Incentive Program?  Alcohol / Drug Testing Program?  Safety Meetings Held?  Meeting Frequency?  Periodic Self-Inspections?  Inspection Frequency:  Written Training Program for New  Employees?  On-going Employee Training?  Bodily Injury Reporting & Record Keeping?  Bodily Injury Investigation?  Return to Work Program?    Any other safety controls in place that assist you in controlling losses?    Yes    No       If YES, please explain below:

General Information 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:  Is entity subject to Jones Act?   If YES, please explain below:  Have you filed bankruptcy in the last five  (5) years? If YES, please explain below:  Is entity subject to Federal Employer's  Liability Acgt? If YES, please explain below:  Do you own, lease, or charter aircraft or  watercraft? If YES, please explain below:  Is entity subject to U.S. Longshore &  Harbor Act? If YES, please explain below:  Do you have, or comtemplate having, any  employees under the age of 18? If YES, please explain below:  Underground / tunneling or sub-aqueous  work? If YES, please explain below:  Do you have, or comtemplate having, any  employees over the age of 65? If YES, please explain below:  Are employee's healthcare plans covered?   If YES, please explain below:  Do you use any leased or temporary  employees? If YES, please explain below:  Are all forklift operators certified?   If YES, please explain below:  Height exposure?   Max: feet If applicant performs work at heights over 15 ft., please explain below:  Maximum weight of material that is  MANUALLY being handled?  Do you use sub-contractors?   If YES, Do you use DWC-85 form?: Yes   No Do you obtain Certificates of Insurance?: Yes   No Please explain all "Yes" answers below:  Does the entity handle, store, or transport  any explosive, caustic? If YES, please explain below:  Has this applicant (or affiliate) been in the  Texas Workers' Compensation System in  the last 3 years? If YES, have they had an experience modification factor of 1.50% or higher?: Yes   No  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:  Has applicant (or affiliate) ever had an  Employer's Liability Claim? If YES, please explain below:  Do you have any out of state operations (i.e. temporary assignments, routine travel, transporation)? If YES, please explain below:  Do you have underground exposure in  excess of 6 feet?   If YES, feet If YES, please explain below:  Does the applicant have Employer's  Excess Indemnity Coverage? If YES, please give Carrier name:

Driving Exposure      Yes       No  Is applicant subject to LPG or TX DOT Regulations?: Yes No  Driving Radius:  Specify commodities hauled:  What % of loads are manually loaded or unloaded?: % Loaded     % Unloaded  Are employees required to drive their own vehicles for business purposes?: Yes No  If "Yes", please explain below:    Are MVRs run at least annually on all drivers?: Yes No  Minimum Standards for Drivers:     Minimum Age yrs.     Maximum Age yrs.  Minimum commercial Truck driving experience:     yrs.  Maximum number of accidents permitted:     (number) in the past years  Maximum number of violations permitted:     (number) in the past years Number of Commercial Units Radius of Operation Private Passenger Light Medium Heavy X-Heavy Tractor 0 - 50 51 - 200 Over 200 Other

Convenience Store      Yes       No  Hours of Operation: (specifically) List hours for each day: Sun:   Mon:   Tue:   Wed:   Thu:   Fri:   Sat:        Has the store ever been robbed?: Yes No  If "Yes", please give details below:    Does the store also offer gasoline/kerosene?: Yes No  If "Yes", give hours of operations, if different from store hours, or type "Same" below:    How much cash do they keep on hand?:  What type of security is in place? Comments:    What type of training is given to employees in case of a robbery?:    What is the minimum # of employees working at any one time?:  Additional Comments:

Please Select Coverages to be Quoted Please select at least one option from each column! Limits Deductible or SIR (Self Insured Retention) Maximum Weekly Disability Benefit Period Waiting Period for Disability   $100,000   $250   $200   104 Weeks   7 Days   $200,000   $500   $300   156 Weeks   14 Days   $250,000   $1,000 (Min. for Emp. Liab.)   $400   208 Weeks   30 Days   $300,000   $2,500   $500   260 Weeks     $500,000   $5,000   $600       $750,000   $7,500   $700       $1,000,000   $10,000         Other:     $25,000           $50,000       Employer's Excess Indemnity   $75,000       -- Please Select -- $1 Million $2 Million $3 Million $4 Million $5 Million   $100,000           Other:         Waiver of Subrogation?  Yes    No Occupational Disease * Cumulative Trauma?  Yes    No Current: Workers' Compensation Premium: Occupation Accident Premium: Are you the current writing agent on this account?  Yes    No

Comparison Chart  If more than one carrier is quoted for this client we can provide a spreadsheet in a chart format.  Would you like to have a comparison chart done?  Yes    No

Additional Comments

Agent and applicant hereby acknowledge that: (a) All answers and statements contained herein, including any attached data, are true and complete; (b) Insurer will rely solely on the information provided in this WebQuote, along with any attached data, in considering whether to provide the requested insurance coverage.

Agency Name:   Producer Name: Phone:             Fax: Mailing Address: City:   State:   Zip Code: Agent's Email:   Re-type Agent's Email (to Confirm): Agency Website:   Date: Are you currently contracted with Comp Solutions?  Yes    No

 

Training and Education  Would you or your agency like to set up an in house training class on Nonsubscription? Yes No  Name of person to contact:       Phone Number:

 
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