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Company Name
Email
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Physical Address of Business (if different from above)
Street Address
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City
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American Samoa
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Connecticut
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Ohio
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Rhode Island
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Texas
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U.S. Virgin Islands
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West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
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Website
Principle(s)/ Owner(s) Name
First
Last
Years in Business
Business Type
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Individual
Corporation
LLC
Partnership
S-Corp
Other
FEIN #
Number of Full Time Employees
Average Tenure of FT Employees
Do you ever hire P/T or seasonal Employees?
Yes
No
Total Annual Payroll
% Payroll Paid to P/T or Seasonal Employees:
States of Operation
Florida
California
Idaho
Montana
New Jersey
New York
North Dakota
Oregon
South Dakota
Washington
Wisconsin
State Licenses & Dates of Issue:
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Name of License
License #
State
Date of Issue
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Detailed description of Employee duties/Operations:
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Please provide descriptions of activities your employees are engaged in and the number of employees for each activity below:
What is the % of work that you sub out (1099)?
Does insured keep certificates of insurance as evidence for all sub-contractors used?
Yes
No
Do you Offer Health or Medical Benefits to ALL of Your Full Time Employees?
Yes
No
Do you Offer a 401K or Form of Profit Sharing to your Full Time Employees?
Yes
No
Do you provide Transportation to and from Jobsites for your Employees?
Yes
No
If yes, how many employees per vehicle:
Do you have a Formal Safety Program? (If yes, please provide a copy)
Yes
No
Do you ever Perform Work below a Depth of 2 feet?
Yes
No
If yes, please provide a detailed description, including equipment used, and the maximum depth exposure in feet:
Do you ever Perform Work above a Height of 6 feet?
Yes
No
If yes, please provide a detailed description, including equipment used, and the maximum height exposure in feet:
Is there any exposure to roofing or do employees ever get on rooftops as part of their job?
Yes
No
If yes, please explain % and nature
How many consecutive nights per year do employees travel and stay overnight?
What other states do employees travel to and how often?
Has insured ever had an OSHA violation?
Yes
No
If yes, please give details and dates:
Have you ever had Insurance Coverage Cancelled for Non-Payment of Premium?
Yes
No
If yes, have all bills been taken care of, to date?
Yes
No
Does this risk generally stay within a local radius of travel (50 miles or less)?
Yes
No
If no, please explain in detail & give max radius:
Do you check MVRs on all drivers?
Yes
No
How many times per year?
Do you Require Pre-Employment Drug Tests?
Yes
No
Do you Require Random Tests?
Yes
No
Do you act as a General Contractor in any capacity?
Yes
No
Are you a licensed GC?
Yes
No
Please provide a list of all Motor Vehicles Owned by this Company:
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Year
Make
Model
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Please provide a list of all Mechanical/Electrical/Motorized Equipment Owned by this Company and used in work:
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Click plus sign at the end of column to add additional equipment
Do you Rent or Lease Equipment to Perform any of your Work?
Yes
No
Please provide a description of all Equipment Rented or Leased by this Company:
Click plus sign at the right end of the column to add additional equipment
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Does this operation involve any of the following:
Select ONLY the ones you are answering YES to. hold control to de-select.
USL&H (navigable waterway or vessel) exposure
Bucket trucks, Boom trucks, Scissor lifts
Tree work (trimming/pruning)
Hazardous chemical exposure
Exterior window washing
Manual lifting over 50 pounds
Asbestos or mold exposure, or Chinese drywall
High voltage work
Clearing of right-of way
Overnight stay
Pile driving
Boiler work
Gas main or pipe exposure
Stone/marble cutting, crushing, or grinding
Use of scaffolding (if yes, fully explain % of use and height)
Extension ladders (if yes, fully explain % of use and height)
Roadway or Roadside work of any kind
Bridge or culvert work
Demolition, wrecking or blasting
Any employee not wearing personal protective wear
Elevator repair, removal or installation
FOR ANY COMPANY IN BUSINESS LESS THAN 24 MONTHS, PLEASE PROVIDE RESUMES FOR ALL OWNERS, PARTNERS OR PRINICIPLES AND COPIES OF THEIR DRIVERS LICENSE
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Accepted file types: pdf, gif, jpg, jpeg, docx, Max. file size: 100 MB, Max. files: 10.
To the best of my knowledge all the information I have given about my business is true and correct. If information is found to be different as the result of my knowingly attempting to defraud the insurance company, or information is concealed for the purpose of misleading, or another person files an application for insurance containing materially false information the insurance company may send direct notice of cancellation.
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I agree to the website disclaimer.
This information is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.
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