Please fill out the following information sheet as completely as possible, so we can provide you with a free and competitive quote for your insurance.
Business Information
Business Description
Individual Included/Excluded
Prior Carrier Information
General Information Answer each of the following questions either "yes" or "no." Explain all "yes" answers in the box provided below.
Comments
Employee Information
Employee Benefits
Average number of employees excluding officers, partners, and sole solicitors:
Full Time Part time
W-2’s issued last year :
Average starting wage (per month):
Average wage (per month):
Company paid benefits (check all that are applicable):
Health Disability Sick leave Leave Union Other
Management
Number of years experience of management? Is this business owner managed? Yes No Designated medical provider: If workplace is bilingual, are supervisors bilingual? Yes No Are supervisors accountable for safety? Yes No Employee Selection & Workplace Safety Check all that are applicable Written employment application Written orientation program Written discipline procedure Early return to work program Safety incentive program Pre-employment physicals Drug screening Reference checks MVR checks Use of personal protective equipment enforced Exposures control Claims History If there have been claims in any of the following categories, please indicate and explain in the comments box below. Losses over $25,000 Psychological stress Accidents involving multiple employees Harassment/Wrongful discharge Attacks/Physical violence against employees Cumulative/Repetitive trauma Employer’s liability Please explain any claims in the comment box below:
Number of years experience of management?
Is this business owner managed? Yes No
Designated medical provider:
If workplace is bilingual, are supervisors bilingual? Yes No
Are supervisors accountable for safety? Yes No
Employee Selection & Workplace Safety Check all that are applicable Written employment application Written orientation program Written discipline procedure Early return to work program Safety incentive program Pre-employment physicals Drug screening Reference checks MVR checks Use of personal protective equipment enforced Exposures control
Claims History If there have been claims in any of the following categories, please indicate and explain in the comments box below. Losses over $25,000 Psychological stress Accidents involving multiple employees Harassment/Wrongful discharge Attacks/Physical violence against employees Cumulative/Repetitive trauma Employer’s liability Please explain any claims in the comment box below: