Accident Fund Workers Compensation Insurance Application Questions

ALLCHOICE Agent Information

Select Your Advisor*

INSURED INFORMATION

Applicant Name (Name of Business)*

Primary Contact*

First Last

Mobile Phone*

Primary Email*

Are Mailing & Location Address Different*

No
Yes

Mailing Address*

Street Address City State ZIP Code

Location Address

Street Address City State ZIP Code

Are there additional locations?*

No
Yes

List other locations (include full address)

Legal Entity Type*

Tax | Federal ID*

Number of years in business*

Number of Employees*

Annual Revenue*

Annual Payroll*

Pay Plan Selection*

INDIVIDUALS INCLUDED / EXCLUDED

Number of Owners | Officers | Partners*

Owner | Officer | Partner 1*

First Last

Owner | Officer | Partner 1 - Date of Birth*

Owner | Officer | Partner 1 - Title*

Owner | Officer | Partner 1 - Ownership %*

Owner | Officer | Partner 1 - Duties*

Owner | Officer | Partner 1 - Payroll | Compensation*

Owner | Officer | Partner 1 - Include | Exclude From Coverage*

Owner | Officer | Partner 2

First Last

Owner | Officer | Partner 2 - Date of Birth

Owner | Officer | Partner 2 - Title

Owner | Officer | Partner 2 - Ownership %

Owner | Officer | Partner 2 - Duties

Owner | Officer | Partner 2 - Payroll | Compensation

Owner | Officer | Partner 2 - Include | Exclude From Coverage

Owner | Officer | Partner 3

First Last

Owner | Officer | Partner 3 - Date of Birth

Owner | Officer | Partner 3 - Title

Owner | Officer | Partner 3 - Ownership %

Owner | Officer | Partner 3 - Duties

Owner | Officer | Partner 3 - Payroll | Compensation

Owner | Officer | Partner 3 - Include | Exclude From Coverage

Owner | Officer | Partner 4

First Last

Owner | Officer | Partner 4 - Date of Birth

Owner | Officer | Partner 4 - Title

Owner | Officer | Partner 4 - Ownership %

Owner | Officer | Partner 4 - Duties

Owner | Officer | Partner 4 - Payroll | Compensation

Owner | Officer | Partner 4 - Include | Exclude From Coverage

Owner | Officer | Partner 5

First Last

Owner | Officer | Partner 5 - Date of Birth

Owner | Officer | Partner 5 - Title

Owner | Officer | Partner 5 - Ownership %

Owner | Officer | Partner 5 - Duties

Owner | Officer | Partner 5 - Payroll | Compensation

Owner | Officer | Partner 5 - Include | Exclude From Coverage

PRIOR CLAIMS

Any Workers Compensation Claims In The Past 4 Years?*

No
Yes

Explain (Include Date of Loss, Amount Paid, Description)

INELIGIBILITY INFORMATION

Does applicant engage in nuclear energy?*

No
Yes

Does applicant engage in railroads?*

No
Yes

Does applicant engage in underground mining?*

No
Yes

Does applicant engage in oil and gas drilling, refining, or manufacturing?*

No
Yes

Does applicant engage in commercial airlines?*

No
Yes

Does applicant engage in manufacturing, storage, or transportation of fireworks, nitrogen-glycerin, or other explosive substances or devices?*

No
Yes

Does applicant engage in professional sports teams and.or professional athletes?*

No
Yes

Does applicant engage in asbestos abatement, manufacturing or distribution?*

No
Yes

Does applicant engage in ship building?*

No
Yes

Does applicant engage in explosives manufacturers, haulers, or distributors?*

No
Yes

Does applicant engage in Jones Act, Defense Base Act, Out Continental Shelf Lands Act?*

No
Yes

Does applicant engage in demolition and blasting?*

No
Yes

RESIDENTIAL VS COMMERCIAL VS INDUSTRIAL

What percentage (%) of payroll is for residential work?*

What percentage (%) of payroll is for commercial work?*

What percentage (%) of payroll is for industrial work?*

INSURED'S STATEMENT(S)

Does the applicant own, operate or lease aircraft/watercraft?*

No
Yes

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

No
Yes

Any work performed underground or above 15 feet?*

No
Yes

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

No
Yes

Is applicant engaged in any other type of business?*

No
Yes

Are sub-contractors used?*

No
Yes

Explain (include "for what", and approx annual pay)

Any work sublet without certificates of insurance?*

No
Yes

Is a written safety program in operation?*

No
Yes

Any group transportation provided?*

No
Yes

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

No
Yes

Any seasonal employees?*

No
Yes

Any employees with physical handicaps?*

No
Yes

Do employees travel out of state (from Corporate Domicile State)?*

No
Yes

Are athletic teams sponsored?*

No
Yes

Are physicals required after offers of employment are made?*

No
Yes

Any other insurance with this insurer (Accident Fund)?*

No
Yes

Any prior coverage declined/cancelled/non-renewed (last 3 years)?*

No
Yes

Are employee health plans provided?*

No
Yes

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

No
Yes

Do you lease employees to or from other employers?*

No
Yes

Do any employees predominantly work at home?*

No
Yes

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

No
Yes

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

No
Yes

Are your employees U.S. Citizens, or do they have the legal right to remain and work in the U.S.?*

No
Yes

Does the risk (you) wish to have a medical-benefits deductible quote?*

No
Yes

Is the applicant a 24-hour business?*

No
Yes

Are there employees other than the owner or his/her relatives?*

No
Yes