Workers Compensation - Universal Marketing and management

Submission Date

Policy Holder Name

Business Name

Detailed Description of Business Operations

Website

Link Text (optional) *

Phone

Email Address

Address *

State

Zip Code *

City

Business Start Date

If Insurance type is not listed Please write type needed here

Provide EIN Number if Workman's Compensation is needed. *

Projected Annual Revenue *

How many full time employees? *

How many part time employees? *

Projected Annual Payroll *

Have you had any Business Insurance Claims in the last 5 years?

Are you currently insured? *

If Currently insured please enter carrier name. *

Please Enter Policy Number *

If currently insured. What is your annual premium? *

Years of experience *

Do you have a Security or Camera system? *

Do you have a Fire Alarm? *

Do you have a sprinkler system *

Type of Company *

What Industry do you work in? *

How did you hear about us? *

Does applicant own, operate or lease Aircraft/Watercraft ? *

Do / have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous materials? (e.g. landfills, wastes, fuel tanks, etc) *

Any work performed underground or above 15 feet? *

Any work performed on barges, vessels, docks, bridge over water? *

Is a written safety program in operation? *

Is applicant engaged in any other type of business? *

Are sub-contractors used? *

If "YES", give % of work subcontracted

Any work sublet without certificates of insurance? *

If "YES", what is the payroll for this job?

Any group transportation provided? *

Any employees under 16 or over 60 years or age? *

Any seasonal employees? *

Any employees with physical handicaps? *

Is there any volunteer or donated labor? *

If "YES", indicate state(s) of travel and frequency

Are athletic teams sponsored? *

Are physicals required after offers of employment are made? *

Any other insurance with this insurer? *

Any prior coverage declined / Cancelled / Non-renewed in the last three (3) years? *(Missouri Applicants - Do not answer this question)

Are employee health plans provided? *

Do any employees perform work for other businesses or subsidiaries? *

Do you lease employees to or from other employers? *

Do any employees predominantly work at home? *

If "YES", # of Employees:

Any tax liens or bankruptcy within the last five (5) years? *

If "YES", please specify

Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? *

If yes, explain including entity name(s) and policy number(s).