Workers Compensation Supplemental Application

1 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?

2 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?If yes, please provide details:Why/purpose?Who will travel?Where?Duration?Frequency?

3 Tangram Insurance Services, 1 of 9 100+ 50-100 < 50 milesRadius of Operations/travel:Any group transportation of employees?NoYesYesNoIf yes, how provided? Van TruckCar Bus# of employees transported per vehicle:# of vehicles used to transport:Monthly Weekly DailyFrequency:Do any employees work from home?List the # of employees who live or work out of state:LiveWork# of employees:Full time:Part time:Seasonal:Volunteers:(Verify number is consistent with number on Acord App)# of employees per location:#1#2#3#4(If more space is needed please use separate page)# of W-2's issued:Last Year:Previous Year:Any day laborers or temporary/employee leasing?

4 YesNoNoYesYesNoIf yes, please provide detail on separate of union employees:% of non-union employees:How are employees paid? HourlyPiece RateCommissionFlat SalaryOther:Paid Sick Leave?Actual average hourly wage for employees in governing glass $/hourPaid Vacation?Retirement / Pension Plan?NoYesNoYesNoYesNoYesNoYesNoYesYesNo NoYesNoYesYesNoYesNoYesNoYesYesNoYesNoYe sYesNoYesNoYesYesNoYesNoYesYesNoYesNoYes YesNoYesNoYesNoYesNoNoYesNoYesNoYesNoYes NoYesNoYesYesNoYesNoDoes employer contribute?Group Medical Provided?If yes, name of healthcare provider:% of employees enrolled:% paid by employer:Do you use a specific medical provider to treat injured employees?

5 Are you currently participating in a MPN (Medical Provider Network)?If yes, provide the name of current MPN:CPR training provided?# employees certified:Has the ownership of the applicable entity changed within the past 5 years?If yes, please provide details:RTW Program?Does it include salary continuance?Hiring Practices - Employee Section - ClaimsWorkers Compensation Supplemental Application (To be Completed with Acord 130 Application )Written applications ?Pre-hire drug testing?Post Accident drug testing?Reference checks?MVR checks?Pre/post employment physicals?

6 Audio hearing tests?Orthopedic back testing?Do you have formal written accident reports?Formal job descriptions on file?Are there set procedures for reporting claims?Are personnel files documented for pre-existing injuries? Any interchange of labor?Average claim reporting time frame:Is job specific training provided?Employee Orientation Program?If yes, is the orientation Verbal Only?Verbal and Documented?Employee to Supervisor Ratio:Better than 4-15-16-17-1>7-1 Subcontractors used?If yes, for what purpose?If yes, are certificates of insurance obtained and kept on file?

7 Independent Contractors Used?If yes, for what purpose?If yes, how are they paid?1099's?Other?Please explain:Safety Program and Organization - Work Premises and EnvironmentActive injury & illness prevention program?Are owners active in daily operations?Has Cal/OSHA visited or cited your business in the last year?Has loss control services been performed in the last year?If yes, are they excluded from coverage?Page 2 of 9 Tangram Insurance Services, yes, please explain:Another businessSubsidiarybetween departmentsOther:If yes, please provide explanation on separate Compensation Supplemental Application (To be Completed with Acord 130 Application )YesNoNoYesYesNoActive safety incentive program?

8 Are safety meetings conducted?If yes, does it encompass all employees?What type of incentive?If yes, how often?DailyWeeklyMonthlyQuarterlyOtherDo employees receive safety training/orientation?YesNoN/ANoYesNoYesN oYesN/ANoYesNoYesN/ANoYesNoYesYesNoN/AN/ AYesNoNewGoodAverageNoYesN/AN/ANoYesExce llentVery GoodAverageNoYesLeasedOwned orNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoY esNoYesNoYesNoYesNoYesNoYesYesNoNoYesNoY esNoYesYesNoIf yes, is the training:Formal/DocumentedInformalDo you have a safety director or risk manager?Name / Title:If yes, is the position full time or an additional responsibility of another employee?

9 MSDS (Material Safety Data Sheets) available for all chemicals and products used?Any material handling exposures?If yes, please explain:Any lifting exposures?If yes, <25 lbs25-4040+Forklift Training Provided?If yes, annual certification?If 40+, manual lifting or with assistance?Please explain:Is all machinery/equipment properly guarded?Any use of Baler equipment?Written Lock out/ tag out / block out procedures in place?Respiratory program in place?What is the maximum height at which you will work?Condition of equipment?Are all equipment operators trained / certified?

10 Personal protection equipment provided?What is used?If scaffolding used, does the insured build their own?Is the building / premises:Condition of premises?LadderScaffoldingScissor LiftsN/AIf yes, strict enforcement of utilization?What types of PPE?# of years at current location?Age of building occupied?yearsAgriculture - FarmingIs harvesting mechanized or manual?Do you use contracted labor?Any seasonal Workers used for operations?If yes, provide details of when season begins and ends, # of seasonal employees hired, and if same employees used each season Are employees transported by any vehicles on or off the premises?