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For Occupational Accident (Non-Subscriber) Programs
       
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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

 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?
 Is entity subject to Jones Act?
 
 Have you filed bankruptcy in the last five
 (5) years?
 Is entity subject to Federal Employer's
 Liability Acgt?
 Do you own, lease, or charter aircraft or
 watercraft?
 Is entity subject to U.S. Longshore &
 Harbor Act?
 Do you have, or comtemplate having, any
 employees under the age of 18?
 Underground / tunneling or sub-aqueous
 work?
 Do you have, or comtemplate having, any
 employees over the age of 65?
 Are employee's healthcare plans covered?
 
 Do you use any leased or temporary
 employees?
 Are all forklift operators certified?
 
 Height exposure?   Max: feet
 Maximum weight of material that is
 MANUALLY being handled?
 Do you use sub-contractors?
 
 Does the entity handle, store, or transport
 any explosive, caustic?

 Has this applicant (or affiliate) been in the
 Texas Workers' Compensation System in
 the last 3 years?
 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?
 Has applicant (or affiliate) ever had an
 Employer's Liability Claim?
 Do you have any out of state operations
(i.e. temporary assignments, routine travel,
transporation)?
 Do you have underground exposure in
 excess of 6 feet?   If YES,
feet
 Does the applicant have Employer's
 Excess Indemnity Coverage?

 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
     
 
$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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