(If more than One. Minimum payroll $20,800.00 per year per employee, $26,000.00 For the state of California, Must meet the minimum Limit per employee.)
#1 During the last 3 years have there been any losses? Yes No
#2 Does applicant own, operate or lease aircraft / watercraft? Yes No
#3 Any work performed under, on or above water? Yes No
#4 Any work performed underground or higher than 15 feet above ground level? Yes No
#5 Any operations include excavation, tunneling, road boring, earth moving or other underground work? Yes No
#6 Any operations exposure to radioactive/nuclear materials? Yes No
#7 Any fatalities in the past five years? Yes No
#8 Is applicant involved in any business other than that specified in the description of operations? Yes No
#9 Do employees travel out of state or out of country? If so, scope of travel? Yes No
#10 Any group travel, ride - share programs, or tool or vehicle allowances provided? Yes No
#11 Does the radius of operations of vehicles exceed 200 miles? Yes No
#12 Are MVRs checked on all drivers? Yes No
#13 Is a written safety program in place? If so, what is the schedule of meetings? Yes No
#14 Has applicant been inspected by OSHA in the past three years?* Yes No
#15 Was applicant cited for any violations ? If so, explain. Yes No
#16 Was applicant fined? If so how much? Yes No
#17 Are any subcontractors used? If yes, list percent, type and location of work subcontracted. Yes No
#18 Are all subcontractors insured? Yes No
#19 If so, does applicant keep copies of certificates of insurance? Yes No
#20 Any prior coverage declined, cancelled or non - renewed in the past three years? Yes No
#21 If any roofing work is performed, is any hot tar or hot mops used? (If Yes, what is the percent of all work performed? Yes No
#22 If any tree trimming work is performed, are any climbers or bucket trucks used? Yes No
#23 Please provide the percentages of commercial and residential work.

SUBMIT Then scroll back to the top make sure you get a green bar or fix the red x, then submit again.

NOTE : Any person who knowingly and with intent to injure, defraud, or deceive any insurer files, statement of claim or an application containing any false, incomplete, or misleading information with the purpose of avoiding or reducing the amount of premiums for workers compensation coverage or conceal information pertinent to the computation and application of an experience rating modification factor, is guilty of a felony of the third degree or as otherwise punishable as provided under the law.

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