Transcription of Workers Compensation Supplemental Application
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Workers Compensation Supplemental Application
Workers Compensation Supplemental Application (To be Completed with Acord 130 Application )Named Insured:Insured's FEIN:Web Address:Contact Name and Phone NumberInspections:Premium Audit:Claims:())()(---Prior Payroll and Premium InformationCurrent Year:Total Annual PayrollPremium $Prior YearPrior YearPrior YearPrior YearOperations and BenefitsBroker Controlled Account?Please provide a description of the operation:Years in business?:Hours of Operation:toNoYesYesNo# of Shifts:Does the applicant ever allow employees to work more than 3 consecutive 12 hour shifts?Is there a driving/delivery exposure?If yes, what is frequency?Is a PUC/DMV filing required?Are vehicles company owned?If yes, types of vehicles:If yes, are vehicles taken home?# of vehicles:Vehicle/fleet maintenance program?If yes, who does the servicing?Do employees use personal vehicles for company business?NoYesNoYesNoYesNoYesNoYesYesNo Daily Weekly Other: N/A DMVPUC Other: In-house mechanics Outside VendorAny out of state, international or overnight (within state) travel?
Workers Compensation Supplemental Application (To be Completed with Acord 130 application) Named Insured: Insured's FEIN: Web …
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