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(If more Then 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?YesNo
#2 Does applicant own, operate or lease aircraft / watercraft?YesNo
#3 Any work performed under, on or above water?YesNo
#4 Any work performed underground or higher than 15 feet above ground level?YesNo
#5 Any operations include excavation, tunneling, road boring, earth moving or other underground work?YesNo
#6 Any operations exposure to radioactive/nuclear materials?YesNo
#7 Any fatalities in the past five years?YesNo
#8 Is applicant involved in any business other than that specified in the description of operations?YesNo
#9 Do employees travel out of state or out of country? If so, scope of travel?YesNo
#10 Any group travel, ride - share programs, or tool or vehicle allowances provided?YesNo
#11 Does the radius of operations of vehicles exceed 200 miles?YesNo
#12 Are MVRs checked on all drivers?YesNo
#13 Is a written safety program in place? If so, what is the schedule of meetings?YesNo
#14 Has applicant been inspected by OSHA in the past three years?*YesNo
#15 Was applicant cited for any violations ? If so, explain.YesNo
#16 Was applicant fined? If so how much?YesNo
#17 Are any subcontractors used? If yes, list percent, type and location of work subcontracted.YesNo
#18 Are all subcontractors insured?YesNo
#19 If so, does applicant keep copies of certificates of insurance?YesNo
#20 Any prior coverage declined, cancelled or non - renewed in the past three years?YesNo
#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?YesNo
#22 If any tree trimming work is performed, are any climbers or bucket trucks used?YesNo
#23 Please provide the percentages of commercial and residential work.
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.

Having any trouble? Contact us!

We specialize in construction class codes:


Roofers, Framers
Steel Erectors
Fabrication
Debris removal
Painting
Siding
HVAC
Plumbing
Construction Supervisors
Masonry and Concrete

And non-construction class
codes:


Health Care Services
Staffing Services
Local Delivery
Moving and Storage
Restaurants
Garbage / Refuse Collection
Landscaping
Are just a few mention.

Quote – Low Rate Workers Comp payroll PEO Quote

Quote – You should consider using an employee leasing company or Professional Employer Organization (PEO), Let Low Rate Workers Comp payroll help.

When you enroll in the program, your employees will be covered by the leasing company’s Workers’ Compensation program.