Supplemental Application
Workers’ Compensation
To be completed with ACORD 130 Application
Named Insured:
Web Address:
Insured’s FEIN:
CONTACT NAME
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
Yes
Does applicant currently use a PEO or payroll service?
No
If yes, provide name of organization used:
Please provide a detailed description of the operation:
Years in business?
No. of shifts:
Hours of operation:
Does the applicant allow employees to work more than three consecutive 12-hour shifts?
Is there a driving or delivery exposure?
Yes
No
If yes, what is the frequency?
Daily
Weekly
Is a PUC/DMV filing required?
PUC
DMV
Are vehicles company owned?
Yes
Radius of operations/travel:
<10 miles
11-50
Any group transportation of employees?
Other:
If yes, how provided?
N/A
Car
Truck
Yes
No
50-100
Yes
100+
No
Van
Bus
No. of employees transported per vehicle:
No
If yes, types of vehicles:
No. of vehicles used to transport:
If yes, are vehicles taken home:
No. of vehicles:
Yes
No
Frequency:
No. of drivers:
Vehicle/fleet maintenance program?
Yes
Daily
Weekly
Monthly
Is insured enrolled in DMV Pull program?
Yes
Are driver acceptability standards in place?
If yes, provide details:
No
If yes, who does the servicing?
Outside vendor:
No
Yes
No
In-house mechanics:
Other:
Does insured have and enforce the following policies for drivers:
Alcohol/drug use: Yes No
Seat belt use: Yes No
Distracted driving:
Yes
Any work-related injuries as a result of a prior motor vehicle accident within the past four years?
No
Yes
No
If yes, please provide details, including fault of accident and if subrogation was pursued:
Do employees use personal vehicles for company business?
Do any employees work from home?
Yes
Yes
No
No. of employees who live/work out of state:
No
Any out-of-state, international or overnight (within state) travel?
Yes
Live:
Work:
No If yes, provide details:
Why/purpose?
Who will travel?
Where?
No. of employees: (verify number is
Full:
Part:
No. of employees per location:
1.
2.
consistent w/ number on ACORD application)
Duration?
Frequency?
Seasonal:
Volunteers:
3.
4.
Average annual employee turnover: _________________________%
No. of W-2s issued: Last Year:
How are employees paid? Hourly:
Flat Salary:
Any interchange labor?
Yes
No
Piece rate:
Commission:
Use a separate page if needed.
Previous Year:
Other:
If yes, please explain: __ Another business __ Subsidiary__ Between departments __ Other
GROW with us ® | 701 B Street, Suite 2100, San Diego, CA 92101 | Tol 800.669.1889 x8733 | ArrowheadGrp.com | CA License #0699809
Yes
Any day laborers or temporary/employee leasing?
% of union employees:
No
Average hourly wage for employees in governing class: $
Retirement/pension plan? Yes No
Does employer contribute?
%of non-union:
Yes
Group medical provided?
No
Yes
No
If group medical is provided, who is the healthcare provider?
% of employees enrolled:
% paid by employer:
Yes
Do you have a wellness program (ie encourages and promotes employee health programs) in place?
Yes No
Do you provide paid sick leave?
Paid vacation? Yes No
Do you use a specific medical provider to treat injured employees? Yes
Are you currently participating in a MPN (Medical Provider Network)?
No
No
Yes
No
If yes, please provide the name of current MPN:
Yes
CPR training provided?
No
Yes
Return to Work Program (RTW) in place?
No. of employees certified?
Yes
Does it include salary continuation?
Has the ownership of the applicable entity changed within the past five years?
Yes
No
No
No
If yes, please provide details:
HIRING PRACTICES - EMPLOYEE SELECTION - CLAIMS
Written application?
Reference checks?
Yes
Pre-hire drug testing?
No
Yes
Background checks? Yes
No
MVR checks?
Pre/post employment physical? Yes
Orthopedic back testing? Yes
No
Formal job descriptions on file?
Yes
No
No
No
Yes
No
Yes
No
Yes
No
Are supervisors held accountable for injuries/accidents?
No
Employee Orientation Program?
Yes
No
If yes, is the orientation:
Better than 4-1
5-1
6-1
7-1
Verbal only?
Yes
No
Verbal and Documented?
>7-1
If yes, for what purpose?
No
If yes, are certificates of insurance obtained and kept on file?
Independent contractors used?
If yes, how are they paid?
Yes
Are there set procedures for reporting claims?
Yes
Yes
No
Do you have a formal written accident report?
Is job specific training provided?
Employee to Supervisor ratio:
Yes
Audio hearing tests?
No
Average claim reporting time frame:
Subcontractors used?
Yes
Post-accident drug testing?
No
Yes
Yes
1099s?
No
If yes, for what purpose?
No
Other? Please explain.
SAFETY PROGRAM AND ORGANIZATION - WORK PREMISES AND ENVIRONMENT
Are owners active in daily operations?
Yes No
Active injury & illness prevention program? Yes No
If yes, are they excluded from coverage?
Yes No
Has loss control services been performed in the last year? Yes
No
Active safety incentive program?
Has Cal/OSHA visited/cited your business in the last year? Yes
No
Yes
No
If yes, does it encompass all employees?
Yes
If yes, please provide explanation on separate page.
No
What type of incentive?
Are safety meetings conducted?
Yes No
Informal
If yes, how often? Daily
Yes
Name and title:
Do employees receive safety training/orientation?
If yes, is the training:
Formal / Documented
Do you have a safety director or risk manager?
No
Yes
Weekly
No
Monthly
Quarterly
Other
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?
Any material handling exposures?
Any lifting exposures?
If yes,
<25 lbs.
Yes
25-40
Yes
Yes
No
N/A
If yes, please explain:
No
Forklift training provided?
No
40+
Yes
If yes, annual certification?
No
Yes
N/A
No
If 40+, manual lifting or with assistance? Explain:
Is all machinery/equipment properly guarded?
Yes
No
N/A
Written lockout/tagout/blockout procedures in place?
Yes
No
Condition of equipment?
N/A
Respiratory program in place?
Yes
Age of equipment?
No
What is the maximum height in feet you will work?
What is used?
Ladder
Scaffolding
Any use of Baler equipment?
Scissor lifts
Yes
New
0-5 years
No
Good
5-10
Average
10-20
20+
Please see Contractors Section for further elaboration.
N/A
If scaffolding used, does the insured build their own?
Yes
If insured builds own scaffolding, provide % of annual operations involving scaffold setup and teardown compared to total operations:
Written Fall Protection Program?
Yes
Are all equipment operators trained/ certified? Yes
Is the building/premises:
Owned
Condition of premises?
Excellent
No. of years at current location?
Please see Contractors Section for further elaboration.
No
No
N/A
Leased?
Very good
Personal protection equipment provided?
If yes, strict enforcement of utilization?
Average
What types of PPE?
Number of years of building occupied?
Yes
Yes
No
No
N/A
No
AUTOMOTIVE REPAIR / TOWING
Are you a member of an Association?
Types of vehicles serviced:
Yes
Private Passenger
Buses
Yes
Any transportation of customers provided?
Yes
Yes
Commercial Vehicles >15K Gross Vehicle Weight Rating
Trailers
Motorhomes
All Terrain
No
Yes
Services include tire repair/sales/installation?
Any engine rebuilding?
Motorcycles
Commercial Vehicles>25K Gross Vehicle Weight Rating
Any test driving of customer’s vehicles?
Any transmission rebuilding?
If yes, provide list of Associations:
No
If yes, what radius?
No
Yes
If yes, amount of total operation___% If above 10%, complete Tire Section.
No
What % of total operations? ______%
No
What % of total operations? ______%
No
What equipment is utilized to lift heavier auto parts?
Yes
Are employees Automotive Service Excellence trained & certified?
No
If yes, what percentage of total workforce? ______%
Number or percentage of Master Technicians on staff _______
Any mobile operations?
Yes
Services include towing?
If yes, is towing for
If yes, what percentage of total operation is mobile? ________%
No
Yes
No
Customers only?
Highway Patrol?
Municipalities?
AAA?
Other? If other, provide details:
What percentage of total operations involves towing____%
What is towing radius?
50 miles
Types of vehicles towed:
51-100 miles
Private Passenger
Buses
24 hours towing provided?
+250miles
Commercial Vehicles >15K Gross Vehicle Weight Rating
Commercial Vehicles>25K Gross Vehicle Weight Rating
Yes
Roadside repair operations?
101-250 miles
Motorcycles
Yes
Are tow trucks equipped with GPS tracking?
No
Hours of roadside repair?
Do drivers carry firearms?
All Terrain
Are tow trucks equipped with scanners?
No
Yes
Trailers
Motorhomes
No
Yes
No
What percentage of total operations?_____%
Yes
Yes
Any accident scene recovery operations?
No
Any vehicle repossession operations?
Yes
Any underwater recovery?
No
Yes
No
No
AUTO BODY REPAIR
Are you a member of an Association?
Types of vehicles serviced:
Yes
No
Private Passenger
Buses
If yes, provide list of Associations:
Motorcycles
Comm’l Vehicles >15K Gross Vehicle Weight Rating
Comm’l Vehicles>25K Gross Vehicle Weight Rating
Are employees Automotive Service Excellence trained & certified?
Is applicant an I-Car Gold Member?
Yes
Yes
No
Trailers
All Terrain
If yes, what percentage of total workforce? ______%
What percentage of technicians are I-Car certified? _____%
No
Do you belong to a Direct Repair Program (DRP)?
Yes
No
If yes, list endorsing insurance carriers:
Paint booth used?
Yes
No
Is paint booth properly filtered/ventilated?
Is it UL certified?
Yes
No
Are flammables stored inside the booth?
Yes
Formal written respiratory program in place?
No
Are employees properly trained in use of respiratory equipment?
Do employees complete a medical evaluation questionnaire?
If yes, is it reviewed by a physician?
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
If yes, what percentage of total operation is mobile? ________%
Yes
Any transportation of customers provided?
Any towing services provided?
Yes
No
No
No
No
Any test driving of customer’s vehicles?
Yes
Yes
Does the booth have automatic fire suppression?
Has proper fit testing been provided to each employee and their assigned respirator?
Any mobile operations?
Motorhomes
No
Yes
No
If yes, what radius?
No If yes, please complete all towing-related questions in above section.
AUTO SERVICE STATION
Are you a member of an Association?
Yes
Pumps: Full Service?
Yes
If yes, provide list of Associations:
No
No Self Service?
Yes
No
Yes
Do services include auto repair?
No
If yes, please complete above auto repair section.
Yes
Is there a car wash on premises?
Is the cashier’s booth bullet proof?
No
Yes
Is it automated?
Any security/surveillance cameras on premises?
Is there a mini market on premises?
Access to freeway?
0-1 mile
Any mobile operations?
Yes
Yes
Yes
No
No
Yes
No
Yes
Are operations 24 hours?
No
Any sales of alcoholic beverages?
No
1-2 miles
Yes
Drop safe registers?
No
Yes
No
+2 miles
No
If yes, what percentage of total operation is mobile? ______%
AUTO PARTS
Are you a member of an Association?
Yes
If yes, provide list of Associations:
No
Be sure to complete delivery/driving exposure questions on page 1 of this supplemental application.
Gross receipts wholesale? ____%
Any assembly?
Yes
Gross receipts retail? ____%
No
If yes, provide details:
Yes
Is product palletized?
No
Max weight lifted manually? _______lbs
Lifting exposure or repackaging?
Yes
Are operators trained & certified?
Use of forklifts?
No
Yes
No
Yes
No
List other mechanical devises for lifting:
TIRE SERVICE
Are you a member of an Association?
Types of vehicles serviced:
Yes
Split rim servicing?
Yes
Motorcycles
Commercial Vehicles >15K Gross Vehicle Weight Rating
Commercial Vehicles>25K Gross Vehicle Weight Rating
Trailers
No
Any recapping operations?
All Terrain
Yes
No
Are tire safety cages utilized when inflating?
No
Max weight lifted manually? _____lbs
Are operators trained & certified?
Motorhomes
If yes, what percentage of total operation is mobile? ________%
No
Yes
Any retreading operations?
If yes, provide list of Associations:
No
Private Passenger
Buses
Any mobile operations?
Yes
Yes
Use of forklifts?
Yes
Yes
No
No
No
AUTO DISMANTLING
Are you a member of an Association?
Types of vehicles dismanted:
Yes
No
Private Passenger
Buses
If yes, provide list of Associations:
Motorcycles
Commercial Vehicles >15K Gross Vehicle Weight Rating
Commercial Vehicles>25K Gross Vehicle Weight Rating
Are vehicle tanks drained of gas and other automotive fluids at time of vehicle arrival at facility?
Who removes air bags?
Yes
Motorhomes
All Terrain
No
If insured’s employees, is any special training provided?
Any vehicle crushing operations?
Any stacking of vehicles?
Trailers
Yes
Yes
Yes
No
No
No
Any dogs on premises for security or other reasons?
If yes, provide max height of stacking _____ft.
Yes
No
If yes, provide details:
Any welding performed?
Yes
No
If yes, you must complete the Welding Exposure Supplemental App and include it with your submission. Visit ArrowheadGrp.com for the form >>
Use of forklifts?
Yes
No
Are operators trained and certified?
Yes
No
List other mechanical devises for lifting:
Thank you.
07.21.2016