Acord 130 Workers Compesation - Universal Marketing and management

Acord 130 Workers Compensation Application

Date Of Submission

Proposed Effective Date

Proposed Expirated Date

Company Name

Contact Name

Contact type

Date of Birth

Email Address

Phone

Street address

City, State, Zip Code

Year in Business

Federal Employer ID Number

What's the type of company

Describe if Other

Full time Employees

Part time employees

Estimated Annual remuneration

Estimated Annual Premium

Workers Compensation State

CLASS CODE

Categories , Dulties, Classification

Give comments and description of business, operation and product

1.Does applicant own, operate or lease aircraft/watercraft?

2. Do/Have past, present or discontinues operations involve(d) storinf, treating, dischaging, applying, disposing, or transporting of hazardous material?(e.g. landfills, wastes, fuel tanks, etc)

3. Any work perfomed undergroup or above 15 feet?

4. Any work perfomed on barages ,Vessels, Docs, Bridge, over water?

5. Is applicant engaged in any other type of business?

6. Are sub-contractor used? (if yes , give % of work subcontractors.

7. Any work sublet without certificates of INS ?

8. Is a written safety program in operation?

9. Any group transportation provide?

10. Any employer under 16 or 60 years of age?

11.Any seasonal employer ?

12.Is there any volunter or donated labor?

13. Any employer with physical handicaps?

14.Do employer travel out of state?

15.Are athletic teams sponsored?

16. Are physicals required after offers of employer are made?

17. Ant other insurance with this insurer?

18. Any prior coverage declined/cancelled/non-renewed(Last 3 years)?

19. Are employer health plans provided?

20. Is there a labor interchange with any other business/subsidiary?

21. Do you lease employer to or from other employer ?

22. Do any employer predominatly work at home?

23. Any tax liens or bankruptcy within the last 5 years?

24. Any udesputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? if yes, explain including entity name(s) and policy numbers(s)