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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?
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If YES, please explain below:
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Is entity subject to Jones Act?
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If YES, please explain below:
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Have you filed bankruptcy in the last five (5) years?
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If YES, please explain below:
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Is entity subject to Federal Employer's Liability Acgt?
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If YES, please explain below:
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Do you own, lease, or charter aircraft or watercraft?
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If YES, please explain below:
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Is entity subject to U.S. Longshore & Harbor Act?
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If YES, please explain below:
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Do you have, or comtemplate having, any employees under the age of 18?
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If YES, please explain below:
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Underground / tunneling or sub-aqueous work?
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If YES, please explain below:
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Do you have, or comtemplate having, any employees over the age of 65?
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If YES, please explain below:
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Are employee's healthcare plans covered?
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If YES, please explain below:
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Do you use any leased or temporary employees?
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If YES, please explain below:
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Are all forklift operators certified?
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If YES, please explain below:
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Height exposure? Max:
feet
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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?
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Please explain all "Yes" answers below:
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Does the entity handle, store, or transport any explosive, caustic?
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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?
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If YES, please explain below:
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Has applicant (or affiliate) ever had an Employer's Liability Claim?
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If YES, please explain below:
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Do you have any out of state operations (i.e. temporary assignments, routine travel, transporation)?
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If YES, please explain below:
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Do you have underground exposure in excess of 6 feet? If YES, feet
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If YES, please explain below:
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Does the applicant have Employer's Excess Indemnity Coverage?
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If YES, please give Carrier name:
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