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?

3 Who will travel?Where?Duration?Frequency?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?

5 If yes, name of healthcare provider:% of employees enrolled:% paid by employer:Do you use a specific medical provider to treat injured employees?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 ?

6 Pre-hire drug testing?Post Accident drug testing?Reference checks?MVR checks?Pre/post employment physicals?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?

7 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?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?

8 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?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?

9 YesNoN/ANoYesNoYesNoYesN/ANoYesNoYesN/AN oYesNoYesYesNoN/AN/AYesNoNewGoodAverageN oYesN/AN/ANoYesExcellentVery 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?MSDS (Material Safety Data Sheets) available for all chemicals and products used?Any material handling exposures?

10 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?Personal protection equipment provided?What is used?