Fillable Workers Compensation Supplemental Application (Abram Interstate Insurance)

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Workers Compensation Supplemental Application (Abram Interstate Insurance)

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Page 1 of 8
Workers Compensation Supplemental Application
(To be Completed with Acord 130 application)
Named Insured: Web Address:
Insured’s FEIN:
Contact Name and Phone Number
Inspections: ( ) -
Premium Audit: ( ) -
Claims: ( ) -
Prior Payroll and Premium Information
Total Annual Payroll Premium $
Current Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:
Operations and Benefits
Broker controlled account? Yes No
Please provide a detailed description of the operation:
Years in business? Hours of operation- to
# of Shifts - Does the applicant ever allow employees to work more than 3 consecutive 12 hour shifts? Yes No
Is there a driving/delivery exposure? Yes No Radius of operations/travel: <50 miles 50-100 100+
If yes, what is frequency: Daily Weekly Other: Any group transportation of employees? Yes No
Is a PUC/DMV filing required? PUC DMV N/A If yes, how provided? car Truck Van Bus
Are vehicles company owned? Yes No # of employees transported per vehicle
If yes, types of vehicles: # of vehicles used to transport
If yes, are vehicles taken home? Yes No Frequency: Daily Weekly Monthly
# Of vehicles? # Of drivers?
Vehicle/fleet maintenance program? Yes No
If yes, who does the servicing? Outside vendor In-house mechanics Other:
Do employees use personal vehicles for company business? Yes No Do any employees work from home? Yes No
Any out of state, international or overnight (within state) travel? Yes No List the # of employees who live or work out of state:
If yes, please provide details - Live Work
Why/purpose?
Who will travel?
Where?
Duration?
Frequency?
# of employees: Full time Part-time Seasonal Volunteers (Verify number is consistent with the number on Acord App)
# of employees per location: #1 #2 #3 #4 (If more space is needed please use separate page)
# of W-2’s issued – Last year Previous year How are employees paid? Hourly
Any day laborers or temporary/employee leasing? Yes No Piece rate Commission Flat salary
If yes, please provide details on separate page. Other:
% of union employees___% of non-union___If union, Exp. date of contract_____ Paid Sick Leave? Yes No
Actual average hourly wage for employees in governing class $ /hour Paid Vacation? Yes No
Workers Compensation Supplemental Application
(To be Completed with Acord 130 application)
Page 2 of 8
Retirement / Pension plan? Yes No Does employer contribute? Yes No
Group medical provided? Yes No % of employees enrolled
If yes, name of healthcare provider - % paid by employer
Do you use a specific medical provider to treat injured employees? Yes No
Are you currently participating in a MPN (Medical Provider Network)? Yes No
If yes, please provide the name of current MPN:
CPR training provided? Yes No RTW Program? Yes No
# of employees certified? Does it include salary continuation? Yes No
Has the ownership of the applicable entity changed within the past 5 years? Yes No
If yes, please provide details:
Hiring Practices – Employee Selection - Claims
Written Application? Yes No Pre-hire drug testing? Yes No
Reference Checks? Yes No Post Accident drug testing? Yes No
Pre/post employment Physicals? Yes No MVR Checks? Yes No
Orthopedic back testing? Yes
No Audio hearing tests?
Yes No
Formal job descriptions on file? Yes No Criminal Background Checks ?
Yes No
Are personnel files documented for pre-existing injuries? Yes
Yes
No
Average claim reporting time frame -
Any Interchange of labor? Yes
No
Is job specific training provided? Yes No
Another business
Subsidiary
Employee Orientation Program? Yes No
between departments
Other:
If yes, is the orientation Verbal only? Verbal and Documented?
Employee to Supervisor ratio - Better than 4-1 5-1 6-1 7-1 >7-1
Subcontractors used? Yes No If yes, for what purpose?
If yes, are certificates of insurance obtained and kept on file? Yes No
Independent contractors used? Yes No If yes, for what purpose?
If yes, how are they paid? 1099’s? Other? Please explain-
Safety Program and Organization – Work premises and Environment
Are owners active in daily operations? Yes No If yes, are they excluded from coverage? Yes No
Active injury & illness prevention program? Yes No Has loss control services been performed in the last year? Yes No
Active safety incentive program? Yes No Has Cal/OSHA visited or cited your business in the last year? Yes No
If yes, does it encompass all employees? Yes No If yes, please provide explanation on separate page.
What type of incentive? Are safety meetings conducted? Yes No
Do employees receive safety training/orientation? Yes No If yes, how often? Daily Weekly Monthly Quarterly
If yes, is the training - Formal / Documented Informal Other:
Do you have a safety director or risk manager? Yes No Name and title:
If yes, is the position full time or an additional responsibility of another employee?
MSDS (Material Safety Data Sheets) available for all chemicals and products used? Yes No N/A
Any material handling exposures? Yes No If yes, please explain
Any lifting exposures? Yes No Forklift training provided? Yes No N/A
If yes, <25 lbs. 25-40 40+ If yes, annual certification? Yes No
If 40+, manual lifting or with assistance? Please explain
Is all machinery/equipment properly guarded? Yes No N/A Any use of Baler equipment? Yes No
Written Lock out / tag out / block out procedures in place? Yes No N/A Condition of equipment? New Good Average
Respiratory program in place? Yes No N/A Are all equipment operators trained/ certified? Yes No N/A
What is the maximum height at which you will work? Personal protection equipment provided? Yes No N/A
What is used? Ladder Scaffolding Scissor lifts N/A If yes, strict enforcement of utilization? Yes No
If yes, please explain
No
Are there set procedures for reporting claims?
Do you have a formal written accident report?
Yes
No
Workers Compensation Supplemental Application
(To be Completed with Acord 130 application)
C
Page 3 of 8
If scaffolding used, does the insured build their own? Yes No What types of PPE?
Is the building / premises - Owned or Leased? # Of years at current location?
Condition of premises? Excellent Very good Average Age of building occupied? year(s)
Agriculture - Farming
Is harvesting mechanized or manual?
Do you use contracted labor? Yes No Is housing provided? Yes No
If yes, % of use? If yes, # of employees housed -
Any seasonal workers used for operations? Yes No Does all farm machinery have safety guards intact? Yes No
If yes, provide details of when season begins and ends, # of seasonal employees hired, and if same employees used each season
Are employees transported by any vehicles on or off the premises? Yes No If yes, please explain on separate page.
Any use of pesticides or fertilizers? Yes No Any crop dusting operations? Yes No
If yes, applications by Employees? Outside Vendor? If yes, services provided by Employees? Outside Vendor?
Do any family members work in operation? Yes No Any work off premises? Yes No If yes, please explain on separate page.
Dairy Farms:
What is the size of dairy herd? Number of Bulls over 3 years old?
Does risk grow their own feed? Yes No Does risk deliver any of their own milk products? Yes No
Is milking barn – Flat? Elevated? Protective Barriers? Yes No
Average number of milkings per day? Do any employees conduct or complete work on sump pumps? Yes No
Are employees allowed to enter stem pipes around lagoon? Yes No
Are proper safety procedures in place for working near stem pipes, lagoons or sump pumps? Yes No
Any confined spaces exposures? Yes No If yes, please provide details on separate page – include copy of written procedures and details of
Confined Spaces Training.
Automotive Services
Any towing services provided? Yes No Any road repair assistance? Yes No
If yes, any contract towing? Yes No If yes, 24 hour exposure? Yes No
Is there a mini-market on premises? Yes No Any fueling operations? Yes No
If yes, any sales of Alcoholic beverages? Yes No Any security/surveillance cameras on premises? Yes No
Open 24 hours? Yes No Any test driving of customers’ vehicles? Yes No
Is cashier’s booth bullet proof? Yes No Any transportation of customers? Yes No
Access to Freeway? 0-1 mile 1-2 miles 2+ miles
Any off-premises or mobile services? Yes No If yes, provide details including percentage of payroll dedicated:
Any vehicle crushing operations? Yes No
Do you have a ventilated/filtered spray booth for painting operations? Yes No N/A
Do you have a written respiratory protection program? Yes No N/A
If yes, do employees complete a medical evaluation questionnaire? Yes No
If medical evaluation questionnaire completed, is it reviewed by a physician? Yes No
Are employees properly trained in the use and care of respiratory protection equipment? Yes No N/A
Has proper fit testing been provided to each employee and their assigned respirator? Yes No
Any work performed on vehicles greater than 2.5 ton capacity? Yes No
Are employees ASE trained and certified? Yes No If yes, how many employees?
Workers Compensation Supplemental Application
(To be Completed with Acord 130 application)
Page 4 of 8
Contractors
Contractors license number? Years experience in trade?
Estimated annual gross sales? Estimated # of jobs per year?
Percentage of work sub-contracted out? % What type?
If subs used, does insured: Check annually? Directly supervise subs?
Average # of certificates collected annually? Average # of Waivers of Subrogation needed?
Indicate % of work conducted in each of the following operations (must equal 100% for each):
1) New Construction Remodeling Service/Repair
2) Commercial Apts/Condos/Tract Homes Single Custom Homes
3) Interior Exterior If exterior work done, what is the maximum height exposure?
Any use of cranes, booms or similar heavy construction equipment? Yes No
Any work below grade? Yes No Max Depth in feet - % of total work -
Any confined spaces exposures? Yes No If yes, please provide details on separate page – include copy of written procedures and details of
Confined Spaces Training.
Any work involving asbestos, hazardous product abatement, chemical/petroleum products, USL&H, underground tank or pipe replacement?
Yes No If yes, please explain -
Does this risk conduct work for the government or city municipality? Yes No
Is the applicant involved in “Wrap Up” or “OCIP” projects Yes No If yes, please provide percentage of total payroll dedicated to these
projects, and advise detailed procedures on how applicant determines employee split between these projects and other contracts/projects (not
Involving “wrap up” or “OCIP”.
Indicate % of work conducted in each of the following operations or Mark not applicable - N/A
Blasting Drilling Light Pole Work Demolition Tunneling
Grading Wrecking Multi Story Buildings Gas Mains Crane Work
Asbestos Highway Work Scaffold set-up Roofing Concrete Tilt-up
Sewer Exterior Framing Structural Steel Bridge Work Excavation
Supervisory only Street/road work Spray painting Dock/Sea Walls
Apartment Ops / Building Ops / Hotel/Motel
Is housing provided? Yes No Any furnished apartments available? Yes No
If yes, # of employees housed and describe their responsibilities: If yes, % of units furnished? %
Are employees involved in property maintenance? Yes No
If yes, provide details:
Security Guards employed? Yes No Security cameras or other security devices on premises? Yes No
If yes, provide details (i.e. armed or unarmed, hours on premises):
Does management collect payment from resident and/or is banking controlled by employee(s)? Yes No
Are employees responsible for eviction notification and/or enforcement? Yes No
Number of guest rooms? Room rates: <$50 $50-$100 $100+ Rent rooms - Daily Weekly Monthly
Any shuttle, limo or similar service? Yes No If yes, please explain -
Any Restaurant exposures? Yes No Does it include 24 hour room service? Yes No Bar or Lounge Area? Yes No
Any entertainment provided? Yes No If yes, please explain -
Housekeeping exposures: Moving of furniture? Yes No Mattress flipping or rotating? Yes No
If yes, how often and # of employees involved in process?
Janitorial Contractors
Check appropriate exposures in the following areas: Education Facilities Nursing Homes Apartment houses
Hospitals Airports Office Buildings Stores Fire/Flood/Restoration
Government Museums Medical Offices Hotels Manufacturing Plants
Workers Compensation Supplemental Application
(To be Completed with Acord 130 application)
C
Page 5 of 8
Indicate % of services provided (must equal 100%):
General cleaning* Chimney cleaning Debris Clearing Exterior window cleaning above 1
st
floor
Industrial cleaning Ceiling Tile cleaning landscaping Heating, A/C ventilation service
Carpet Cleaning Elevator maintenance Parking lot cleaning Aircraft service and maintenance
Snow removal Maid/housekeeping services Fire/flood restoration Servicing/cleaning of hoods/filters/grease traps/etc
Pest control Floor waxing and refinishing Crime scene clean-up Pressure or steam washing operations
* General Cleaning includes operations such as vacuuming, dusting, wastebasket trash pick up, floor and rug cleaning, restroom clean-up
Do employees work in pairs or more? Yes No Employees supervised? Yes No Direct or Roving supervision?
Landscaping
Any tree trimming performed that is off the ground? Yes No Any boulder or tree removal performed? Yes No
Any use of tractors, loaders or similar equipment? Yes No Any highway or median work conducted? Yes No
Any use of chippers, mulchers, cherry pickers, booms or other similar equipment? Yes No
If yes, please explain -
Any use of pesticides or fertilizers? Yes No
If yes, is the application completed by - Employee? Outside Vendor?
Any debris removal or land clearing activities? Yes No
If yes, please explain -
Manufacturing – Machine Shops
Any punch press or press brake machinery/equipment? Yes No Machine Guarded: Point of operation Drive Mechanism
Age of machinery: <2 yrs 2-5 yrs 5-10 yrs 10+ yrs Accessible moving parts guarded on machinery/equipment? Yes No
Types of machines (must equal 100%) - Heavy Mid Light Any Computer Network Controlled (CNC) machinery? Yes No
% of off-premise operations: If yes, where/what for?
Is building properly ventilated? Yes No Is proper dust collection system in place? Yes No
Restaurants
Entertainment provided? Yes No Bar or separate lounge area? Yes No
Fast Food? Yes No Any catering? Yes No
Number of: Hosts Waitpersons Bartenders If yes, radius of operations: miles % of exposure -
Valet Busboys Cooks Any delivery? Yes No Delivery hours - to
Average price of entrée? <$5 $5-$15 $15+ If yes, radius of operations: miles % of exposure -
Servicing, cleaning of hoods/filters/grease traps or related systems provided by: Outside vendor Employees
Retail / Wholesale
Type of Merchandise?
Gross Receipts: Wholesale % Retail % Warehousing? Yes No
Any repacking or repackaging operations? Yes No
If yes, please explain operations:
Assembly exposure? Yes No
If yes, please explain exposure:
Any distribution exposure? Yes No If yes, by common carrier or does insured have a trucking exposure? Please explain on separate page.
Trucking
Type of Authority: a) Common Carrier Contract Carrier Private Brokerage Exempt
b) Regular Route Irregular Route
Carrier Operations: California Only Interstate
Length of Haul with Total % = 100%:
Under 50 Miles % 50 – 200 % 201 – 300 %
301 – 500 % 501 – 1,000 % Over 1,000 %
Filings: DOT# PUC# DMV/MCP# Not Applicable
Please Check the Questions and Attached the Applicable Data:
Motor Carrier Identification Report, MCS-150: Attached or Not Applicable
Workers Compensation Supplemental Application
(To be Completed with Acord 130 application)
C
Page 6 of 8
Cargo Classification: See attached MCS-150 or See below (check all that apply):
General Freight Logs, Poles Beams, Lumber Liquids/Gases Grain, Feed, Hay Chemicals
Household Goods Building Materials Intermodal Containers Coal, Coke Commodities Dry Bullion
Metal Sheets, Coils, Rolls Mobile Homes Passengers Meat Refrigerated Food
Motor Vehicles Machinery, Large Objects Oilfield Equipment Garbage, Refuse, Trash Beverages
Driveway/Towaway Fresh Produce Livestock U.S. Mail Paper Products
Other
Drivers: a) Number of Drivers b) Number of Owner/Operators used
- Percentage where the Motor Carrier will provide workers’ compensation for the Owner/Operators %
- Percentage where the Motor Carrier will agree with the Owner/Operator that the Owner/Operator
assumes the responsibilities of an Employer for the performance of work: %
c) If Owner/Operators used, please attach copy of contract: Attached or Not Applicable
d) Number of company drivers with Motor Carrier at least 12 months:
Number of Owner/Operator with Motor Carrier at least 12 months: or Not Applicable
e) Number of Non-Union: Union:
f) Do the drivers load and unload their trucks? No Yes (please provide detail of the types of materials loaded/unloaded
and any equipment used:
Is the applicant enrolled in the DMV Pull Program? Yes No If so, how often?
Is the applicant enrolled in the CHP BIT Program? Yes No
Total # of Trucks # of Trucks with Sleeper Cabs Single Trailers Double Trailers Triple Trailers
Any trucks / trailers with ramps? Yes No If yes, please provide #
Any trucks / trailers with lift-gates? Yes No If yes, please provide #
Any team driver operations? Yes No If yes, please provide details-
If union operations, provide Month / Year of contract renewal:
Public Entities
Municipality County
Check each applicable operational department / category:
Water Department Power Department Sewer Department Street / Road Department
Street Sweeping / Cleaning Building Inspector Code Enforcement Garbage / Refuse / Recycling
Parks / Recreation Landscape Maintenance Tree Trimming Waste Treatment
Housing Authority Day Care / Child Care Public Housing Nurse Electricians
Painters Mechanic Truck Driver
Fire Department Police Department Animal Control
# F/T Staff # P/T Staff
Any Volunteers or Intern Staff? Yes No If yes, explain
City Council Positions? Yes No #
County Supervisors Positions? Yes No #
Does the hiring process include: Drug Screening? Yes No Pre Employment Physicals? Yes No If yes, explain
Any Post Accident Drug Testing? Yes No
Is there a probationary period upon hire? Yes No If yes, explain
Are employees provided with any New Employee Orientation? Yes No
Does each job have a written job description? Yes No
Do employees receive initial job training? Yes No
Is training on-going and documented? Yes No
Do employees work shifts? Yes No If yes, explain
Any on-call employees? Yes No If yes, explain
Do any employees have take home vehicles? Yes No If yes, explain
Any underground work? Yes No If yes, explain
Workers Compensation Supplemental Application
(To be Completed with Acord 130 application)
C
Page 7 of 8
Any work above 12’ in height? Yes No If yes, explain
Any confined space exposures? Yes No If yes, explain
If yes, is there a Written Confined Space Entry Program? Yes No
Any sub-contracted operations? Yes No If yes, explain
Are W / C Certificates of Insurance obtained on all sub-contractors? Yes No
Any use of independent contractors? Yes No If yes, explain
Number of vehicles? Driving Radius?
Do employees use personal vehicle for business purposes? Yes No If yes, explain
Newspaper / Publishing
Any home delivery services? Yes No If yes, independent contractors and/or employees?
Provide details:
Any delivery operations? Yes No If yes, # of vehicles Driving radius
Any telemarketing operations? Yes No If yes, independent contractors and/or employees?
Provide details:
Any security operations? Yes No If yes, independent contractors and/or employees? Armed or Unarmed?
Provide details:
Do employees or independent contractors use personal vehicle for company business? Yes No
If yes, are certificates of insurance in file? Yes No
Are MVR’s (Motor Vehicle Reports) obtained on all drivers? Yes No Is the Company enrolled in the DMV “Pull” Program? Yes No
Any employee or independent contractor travel: Out of State, Out of Country, On Navigable Waters, within War Zones or Exposure to Civil Disturbances,
Etc.? Yes No If yes, provide details:
Any excessive noise levels within the operations? Yes No If yes, provide details:
Have noise levels been evaluated within the Press / Bindery Areas and/r areas with noise producing machinery and equipment? Yes No
If yes, provide details:
If noise level testing has been completed, are copies of the results available for review? Yes No
Does the company have a written Hearing Conservation Program? Yes No
Do employees use/wear and PPE (Personal Protective Equipment)? Yes No If yes, provide details:
Does the company have a written Ergonomics Program? Yes No
Does the company have a written Material Handling Program, with identified weight limits? Yes No
Does the company have a written Lock Out / Tag Out Program? Yes No
Is maintenance of equipment / machinery completed by employees and/or outside vendors? Yes No If yes, provide details:
Are all forklift / material handling equipment operations certified? Yes No
Pest Control
Type of operations: Commercial Agricultural Residential Industrial Structural
Structural repairs or replacements Dry Rot Wood Repair Shower Pan Replacement
Chemical Treatment Services Fumigation Foam Other
Provide Details:
Percentage of tenting, if any?
Lawn treatment or care? Yes No If yes, provide details:
Other Service
Provide details:
Place an (x) next to each of the applicable services available:
Ants Spiders Roaches Fleas Ticks Wasps
Mosquitoes Bees Killer Bees Bee Removal Mice Termite
Rats Snakes Raccoons Opossum Skunks Bats
Rodents Gopher Control Bird/Pigeon Control Animal Trapping Animal Removal Bird/Rodent Proofing
Other If other, provide details:
Personal protective equipment required:
Workers Compensation Supplemental Application
(To be Completed with Acord 130 application)
C
Page 8 of 8
Written Injury & Illness Prevention Program? Yes No Written Haz-Com Program? Yes No
Written Heat Stress Program? Yes No Written Respiratory Protection Program? Yes No
Written Fall Protection Program? Yes No
Special Written Procedures for working in Confined Spaces (Attics & Under Residences / Buildings)? Yes No
Documented New Employee Orientation including Documented Training? Yes No
Healthcare
Not For Profit
Medicare Certified
Medicaid Certified
For Profit
Hospital Affiliation_______________________________
Religious Affiliation______________________________
JCAHO Accredited (Date)_________________________
Government
Psychiatric Care(excluding depression) _______________% ______________
Dementia/Alzheimer _______________% ______________
Mental Retardation _______________% ______________
HIV (Aids) _______________% ______________
% of Total Residents Separate Unit ?
Other:________________________________________________________________________________________________________________
% of Ambulatory without assistance ________
Please explain any changes during the last 3 years; Or anticipated changes in the next year.___________________________________________
______________________________________________________________________________________________________________________
Does your IIPP (SB198) address the following specific Healthcare related exposures:
Patient Handling ?
Blood-borne Pathogens ?
Aggressive/Combative Behavior ?
Any other ?
Is a Registered Nurse, Manager or supervisor who knows procedures for Workers' Compensation and Safety on each shift ?
Yes
Yes
Yes
Yes
No
No
No
No
Comment:___________________________________
Comment:___________________________________
Comment:___________________________________
Comment:___________________________________
Yes
No
Do you treat any worker injuries on site ?
Are all injuries reported to your insurer ?
Do you have a policy to maintain contact with an injured worker ?
No
No,
Yes,
No
Yes
Yes
Describe_______________________________________
Explain________________________________________
Note: All information provided is subject to verification by way of an underwriting survey or inspection. We must be
notified of any significant change in operations or payroll. Terms of insurance coverage may be cancelled for
misrepresentation if information provided is inaccurate.
Signature of Applicant: ________________________________________________ Date: __________________
For Skilled Nursing Facilities only, Please answer the following:
Within the past year has their been a change in the Administrator or Director of Nursing positions ?
____________________________________________________________________________________________________________________
No Yes, Explain_________________
% turnover of RN/LVN positions during the past year ?____
What % of new residents do you evaluate prior to admission ? __________
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Workers Compensation Supplemental Application (Abram Interstate Insurance)

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Completed 10 July 2021

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