Icw-group-supplemental-application-general



GENERAL SUPPLEMENTAL APPLICATIONInsured: FORMTEXT ?????Address: FORMTEXT ?????Website: FORMTEXT ?????Effective Date: FORMTEXT ?????Do you control this account? FORMCHECKBOX Yes FORMCHECKBOX NoCompleted by: FORMTEXT ?????Date: FORMTEXT ?????OPERATIONS / EXPOSURESDetailed description of the operation: FORMTEXT ?????1. Number of employees is: FORMCHECKBOX Increasing FORMCHECKBOX Decreasing FORMCHECKBOX Stable2. # of W-2’s issued last year: FORMTEXT ?????Future layoffs foreseen? FORMCHECKBOX Yes FORMCHECKBOX No 3. Number of employees: Full time: FORMTEXT ????? Part-time: FORMTEXT ????? Seasonal: FORMTEXT ????? Volunteers: FORMTEXT ????? 4. Employees are paid? FORMCHECKBOX Hourly FORMCHECKBOX Piece Rate FORMCHECKBOX Commission FORMCHECKBOX Flat Salary FORMCHECKBOX Other: FORMTEXT ?????Average hourly wage: FORMTEXT ????? 5. Do any employees work from home? FORMCHECKBOX Yes FORMCHECKBOX No If yes, how many? FORMTEXT ?????What are their duties? FORMTEXT ????? 6.Average length of employment: FORMTEXT ?????Average number of years of experience: FORMTEXT ?????Ratio of supervisors to employees: FORMTEXT ?????Average supervisor length of employment: FORMTEXT ????? Average supervisor years of experience: FORMTEXT ????? 7.Hours of operation: FORMCHECKBOX 24 hours a day FORMCHECKBOX Daily from FORMTEXT ????? FORMCHECKBOX AM FORMCHECKBOX PM to FORMTEXT ????? FORMCHECKBOX AM FORMCHECKBOX PM Number of shifts FORMTEXT ????? Any weekend, night-shift, or graveyard shifts? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please provide details: FORMTEXT ????? Any day-laborers or temporary/employee leasing used? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please provide details FORMTEXT ????? 8. Any off-premises operations? FORMCHECKBOX Yes FORMCHECKBOX No If yes, what percentage FORMTEXT ???% Please describe these operations: FORMTEXT ????? 9. Are you currently participating in a MPN (Medical Provider Network)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes above, please provide the name of current MPN: FORMTEXT ????? 10. Has the ownership of the applicable entity changed within the past 5 years? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes above, please provide details: FORMTEXT ?????11. Does the insured belong to any trade associations? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes please list them: FORMTEXT ????? 12.Any group transportation of employees? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how are employees transported? FORMCHECKBOX Car FORMCHECKBOX Truck FORMCHECKBOX Van FORMCHECKBOX Bus FORMCHECKBOX Other: FORMTEXT ????? Number of employees in a vehicle: FORMTEXT ????? Number of vehicles: FORMTEXT ?????Frequency: FORMTEXT ????? SAFETY PROGRAM1. Does the insured have a full-time Safety Director on staff (no additional job duties)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how long has there been a designated safety person? FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ????? 2. Formal safety incentive program? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what type of incentive(s)? FORMTEXT ?????If yes, does it encompass all employees? FORMCHECKBOX Yes FORMCHECKBOX No 3. Do you have a accident investigation program? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, do you have a formal written accident report? FORMCHECKBOX Yes FORMCHECKBOX No4. Do you have an early return to work program? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is it: FORMCHECKBOX Formal FORMCHECKBOX InformalIf yes, does it include salary continuation? FORMCHECKBOX Yes FORMCHECKBOX No 5. Formal Drug Testing? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Pre-hire FORMCHECKBOX Post Accident 6. Are MVR’s checked Pre-hire and Annually? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A - No driving exposures7. Are owners active in daily operations? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, are they excluded from coverage? FORMCHECKBOX Yes FORMCHECKBOX No 8. Are safety meetings conducted? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, are they: FORMCHECKBOX Formal / documented FORMCHECKBOX Informal 9. Is CPR training provided? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, number of employees certified: FORMTEXT ????? 10. Any material handling exposures? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Please explain: FORMTEXT ?????How much is lifted by hand: FORMCHECKBOX <25 lbs. FORMCHECKBOX 25-40 FORMCHECKBOX 40+List any mechanical lifting devices used: FORMTEXT ?????Forklifts used? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is forklift training provided? FORMCHECKBOX Yes FORMCHECKBOX NoIs there annual Certification for forklift drivers? FORMCHECKBOX Yes FORMCHECKBOX No Number of Forklift Drivers: FORMTEXT ????? Number of forklifts: FORMTEXT ????? 11. Has loss control services been performed in the last year? FORMCHECKBOX Yes FORMCHECKBOX NoHas Cal/OSHA visited or cited your business in the last year? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes to either of the above, please provide explanation: FORMTEXT ????? 12. Is PPE mandatory? FORMCHECKBOX Yes FORMCHECKBOX NoPersonal protection equipment (PPE) provided? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AWhat PPE is used? FORMCHECKBOX Back Belts FORMCHECKBOX Goggles FORMCHECKBOX Masks FORMCHECKBOX Face Guard FORMCHECKBOX gloves FORMCHECKBOX Respirators FORMCHECKBOX Hearing protection devices FORMCHECKBOX Other: FORMTEXT ????? 13. What is used? FORMCHECKBOX Ladder FORMCHECKBOX Scaffolding FORMCHECKBOX Scissor lifts FORMCHECKBOX N/AIf scaffolding is used, does the insured construct their own? FORMCHECKBOX Yes FORMCHECKBOX NoIs there strict enforcement of utilization? FORMCHECKBOX Yes FORMCHECKBOX NoWhat is the maximum height at which you will work? FORMTEXT ????? 14. The building / premises: FORMCHECKBOX Owned FORMCHECKBOX LeasedWhat is the condition of the premises? FORMCHECKBOX Excellent FORMCHECKBOX Very good FORMCHECKBOX Average15. Please answer the following questions by marking the applicable box:Is a respiratory program in place? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AIs all machinery/equipment properly guarded? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AAre all equipment operators trained/ certified? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AWhat is the condition of equipment? FORMCHECKBOX New FORMCHECKBOX Good FORMCHECKBOX Average FORMCHECKBOX N/AMaterial Safety Data Sheets available for all chemicals and products used? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AWritten Lock out/tag out/block out procedures in place? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A PREMIUM / PAYROLLPlease use estimated premium and payroll for the current policy and audited premium and payroll for all prior periods. Please provide payroll and premium going back at least 4 full years. PremiumPayrollCurrent policy period $ FORMTEXT ????? $ FORMTEXT ????? 1st Prior policy period$ FORMTEXT ????? $ FORMTEXT ????? 2nd Prior policy period$ FORMTEXT ????? $ FORMTEXT ????? 3rd Prior policy period$ FORMTEXT ????? $ FORMTEXT ????? Please explain reason(s) for breaks in coverage or policies greater than or less than a full year: FORMTEXT ????? BENEFITS1. Group medical provided? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, name of Healthcare Provider: FORMTEXT ????? % of employees enrolled: FORMTEXT ??? % paid by employer: FORMTEXT ??? If yes, who is eligible: FORMCHECKBOX FT FORMCHECKBOX PT FORMCHECKBOX Seasonal FORMCHECKBOX Management/Supervisors only?2.Paid Sick Leave? FORMCHECKBOX Yes FORMCHECKBOX NoPaid Vacation? FORMCHECKBOX Yes FORMCHECKBOX No3.What is the average weekly wage of the employees in the governing class? $ FORMTEXT ????? 4.Retirement / Pension plan? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, does employer contribute? FORMCHECKBOX Yes FORMCHECKBOX No 5. Do you use a specific medical provider to treat injured employees? FORMCHECKBOX Yes FORMCHECKBOX No HIRING PRACTICESAre personnel files documented for pre-existing injuries? FORMCHECKBOX Yes FORMCHECKBOX No Employee Orientation Program? FORMCHECKBOX Yes FORMCHECKBOX Verbal only FORMCHECKBOX Verbal and Documented FORMCHECKBOX NonePlease answer the following questions by marking the applicable box Written Application? FORMCHECKBOX Yes FORMCHECKBOX NoIs a background checking service used? FORMCHECKBOX Yes FORMCHECKBOX NoReference Checks? FORMCHECKBOX Yes FORMCHECKBOX NoFormal job descriptions on file? FORMCHECKBOX Yes FORMCHECKBOX No Orthopedic back testing? FORMCHECKBOX Yes FORMCHECKBOX NoIs job specific training provided? FORMCHECKBOX Yes FORMCHECKBOX NoAudio hearing tests? FORMCHECKBOX Yes FORMCHECKBOX NoPathogenic test (i.e. lead)? FORMCHECKBOX Yes FORMCHECKBOX NoDRIVING EXPOSURES1. Does the insured have employees who perform pick-up or delivery? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how frequently: FORMCHECKBOX Daily FORMCHECKBOX Week FORMCHECKBOX Other FORMTEXT ?????Are motorcycles used for any driving pick-up or delivery operations? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the insured participate in the CHP Pull Program? FORMCHECKBOX Yes FORMCHECKBOX NoTravel Radius: FORMCHECKBOX 50 Miles or Less FORMCHECKBOX 51 – 100 Miles FORMCHECKBOX Greater than 100 Miles# of Vehicles: FORMTEXT ????? # of drivers: FORMTEXT ????? 2.Vehicle/Fleet maintenance program? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, who performs the service? FORMCHECKBOX Outside Vendor FORMCHECKBOX In-house employeesVehicle Inspection program? FORMCHECKBOX Yes FORMCHECKBOX No4. Are company vehicles owned? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, are vehicles taken home? FORMCHECKBOX Yes FORMCHECKBOX No 5. Has a driver acceptability standard been established? FORMCHECKBOX Yes FORMCHECKBOX No 6. Do employees use company vehicles for personal business? FORMCHECKBOX Yes FORMCHECKBOX NoDo employees use personal vehicles for errands or deliveries? FORMCHECKBOX Yes FORMCHECKBOX No 7.Is a PUC/DMV filing program required? FORMCHECKBOX PUC FORMCHECKBOX DMV FORMCHECKBOX N/AIf a PUC/DMV filing is required what is the number? FORMTEXT ????? TRAVEL EXPOSURESAny out of state, international or overnight (within state) travel? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide details and purpose: FORMTEXT ?????Who will travel? FORMTEXT ?????# of employees who travel: FORMTEXT ?????Mode of transportation: FORMTEXT ?????Frequency? FORMTEXT ????? Duration? FORMTEXT ?????Where? FORMTEXT ????? CATASTROPHIC EXPOSUREDoes the insured work within 2 miles of the following: Government or military base, financial institutions, sports stadiums, arenas, theme parks, major bridges, tunnels, dams, utilities/power plants, transportation hubs, railroads, airports, shipping, historic / symbolic buildings, monuments or parks: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain 2. Do they have employees in a 4 story building or greater: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes above, structure of buildings is: FORMCHECKBOX Tilt up Concrete FORMCHECKBOX Masonry FORMCHECKBOX Steel FORMCHECKBOX Wood Frame/StuccoCLAIMSFor claims over $25,000 please advise us of the following on a separate sheet: Was it an accepted claim?Is the employee still working for the insured?How did it occur? What was the injury? What corrective action has the insured taken to prevent reoccurrences? AGRICULTURE / FARMINGInsureds operations (check all that apply): FORMCHECKBOX Farm Labor ContractorFLC #: FORMTEXT ????? FORMCHECKBOX Field CropsCrops/Acres: FORMTEXT ????? FORMCHECKBOX Truck farmCrops/Acres: FORMTEXT ????? FORMCHECKBOX OrchardCrops/Acres: FORMTEXT ????? FORMCHECKBOX Vineyard% of insured’s acreage devoted to growing table grapes: FORMTEXT ????? FORMCHECKBOX LivestockTypes of livestock: FORMTEXT ????? FORMCHECKBOX Dairy FORMCHECKBOX Dude Ranch FORMCHECKBOX Other: FORMTEXT ?????If Strawberry farm, are berries grown in raised beds (2 or more feet)? FORMCHECKBOX Yes FORMCHECKBOX NoDoes insured grow mushrooms? FORMCHECKBOX Yes FORMCHECKBOX No2. Do any family members work in operation? FORMCHECKBOX Yes FORMCHECKBOX No3. Harvesting process: FORMCHECKBOX Mechanized FORMCHECKBOX ManualIf manual, are employees paid by piece (piecework)? FORMCHECKBOX Yes FORMCHECKBOX NoAre pruning operations performed by employees? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX By othersAny crops/orchards located on hillsides or slopes? FORMCHECKBOX Yes FORMCHECKBOX NoDoes insured use an outside vendor for chemical/pesticide application? FORMCHECKBOX Yes FORMCHECKBOX NoDoes insured perform any aerial crop dusting operations? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the insured perform any packing operations of fruits/vegetables in the field? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the insured perform any packing operations of fruits/vegetables away from field? FORMCHECKBOX Yes FORMCHECKBOX No8.Does the insured perform delivery? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, number of delivery vehicles: FORMTEXT ?????Delivery distance: FORMTEXT ?????Does insured employees perform tarping or climb on trucks/trailers: FORMCHECKBOX Yes FORMCHECKBOX No9. Are operations seasonal? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, season begins: FORMTEXT ????? ends: FORMTEXT ?????# of seasonal employees hired: FORMTEXT ?????% of insured’s seasonal employees that return each year: FORMTEXT ?????% FORMCHECKBOX None Is housing provided? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, # of employees housed? FORMTEXT ?????10.Does the insured provide group transportation (4 or more people in one vehicle)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how many employees at one time in one vehicle? FORMTEXT ????? FORMCHECKBOX One parcel to another parcel, within farm FORMCHECKBOX One farm to another farm, less than 10 miles FORMCHECKBOX One farm to another farm, more than 10 miles. Average distance: FORMTEXT ????? miles 11.Does the insured own or operate any ATV’s? FORMCHECKBOX Yes FORMCHECKBOX No12. Any confined spaces exposures? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide details (use separate page if needed): FORMTEXT ????? 13. Is there an extreme temperature program that meets Cal OSHA requirements? FORMCHECKBOX Yes FORMCHECKBOX NoAUTOMOTIVE SERVICES 1. Does the insured have towing, roadside services or mobile operations? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, any contract towing? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is there 24 hour exposure? FORMCHECKBOX Yes FORMCHECKBOX No 2. Is there a Mini-market on premises? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, any sales of alcoholic beverages? FORMCHECKBOX Yes FORMCHECKBOX No Please answer the following questions by marking the applicable box:Open 24 hours? FORMCHECKBOX Yes FORMCHECKBOX NoAny fueling operations? FORMCHECKBOX Yes FORMCHECKBOX NoSecurity cameras used? FORMCHECKBOX Yes FORMCHECKBOX NoAny transportation of customers? FORMCHECKBOX Yes FORMCHECKBOX NoIs cashier’s booth bullet proof? FORMCHECKBOX Yes FORMCHECKBOX NoAny fueling operations? FORMCHECKBOX Yes FORMCHECKBOX No4. Access to Freeway? FORMCHECKBOX 0-1 mile FORMCHECKBOX 1-2 miles FORMCHECKBOX 2+ miles 5. How many employees are ASE trained and certified? FORMTEXT ????? 6. Does the insured have employees participate in/on racing teams or racing events? FORMCHECKBOX Yes FORMCHECKBOX NoCONTRACTORSPlease attach a project list for the last 12 months and a bid list for the next 12 months1. Has the insured been in business with Workers’ Comp Insurance for 3 years or more? FORMCHECKBOX Yes FORMCHECKBOX No2. Does the insured have a current and active Contractor’s License? FORMCHECKBOX Yes FORMCHECKBOX NoContractor’s license number: FORMTEXT ????? Years of experience in trade: FORMTEXT ?????Estimated # of jobs per year: FORMTEXT ????? Indicate % of work conducted in each of the following operations (must equal 100% for each line):New Construction FORMTEXT ??? Remodeling/Service/Repair FORMTEXT ??? = 100%Commercial FORMTEXT ???Residential FORMTEXT ??? = 100%Interior FORMTEXT ???Exterior FORMTEXT ??? = 100%If exterior work is done, what is the maximum height exposure? FORMTEXT ????? 4. Does the insured hire “Day Laborers”? FORMCHECKBOX Yes FORMCHECKBOX No 5. Is the insured a Union Contractor? FORMCHECKBOX Yes FORMCHECKBOX No 6. Any use of cranes, booms or similar heavy construction equipment? FORMCHECKBOX Yes FORMCHECKBOX No 7. Any work below grade? FORMCHECKBOX Yes FORMCHECKBOX NoMax Depth in feet: FORMTEXT ?????Percent of total work: FORMTEXT ???% 8. Any confined spaces exposures? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide details (use separate page if needed): FORMTEXT ????? 9. Any work involving asbestos, hazardous product abatement, chemical/petroleum products, USL&H,underground tank or pipe replacement: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ????? 10. Does this risk conduct work for the government or city municipalities? FORMCHECKBOX Yes FORMCHECKBOX No 11.Is the applicant involved in “Wrap Up” or “OCIP” projects? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide percentage of total payroll dedicated to these projects: FORMTEXT ???%Advise details on how applicant determines employee split between these projects and other contracts orprojects (not Involving “wrap up” or “OCIP”): FORMTEXT ????? 12. Indicate % of work conducted in each of the following operations (if any):Asbestos FORMTEXT ???% Blasting FORMTEXT ???%Bridge Work FORMTEXT ???% Concrete Tilt-up FORMTEXT ???% Crane Work FORMTEXT ???%Demolition FORMTEXT ???%Drilling FORMTEXT ???% Dock/Sea Walls FORMTEXT ???% Excavation FORMTEXT ???% Exterior Framing FORMTEXT ???% Gas Mains FORMTEXT ???%Grading FORMTEXT ???% Highway Work FORMTEXT ???%Light Pole Work FORMTEXT ???% Multi-Story Buildings FORMTEXT ???% Roofing FORMTEXT ???% Scaffold set-up FORMTEXT ???% Sewer FORMTEXT ???% Spray painting FORMTEXT ???%Street/road work FORMTEXT ???% Structural Steel FORMTEXT ???% Supervisory only FORMTEXT ???% Tunneling FORMTEXT ???% Wrecking FORMTEXT ???%13. Does the insured have an extreme temperature program meeting Cal OSHA requirements? FORMCHECKBOX Yes FORMCHECKBOX No JANITORIAL CONTRACTORS1. Which one of the following best describes the insured’s operations (Please select only one option): FORMCHECKBOX Commercial Office Cleaning – No Waxing/Polishing of Floors or Walls FORMCHECKBOX Commercial Office Cleaning – Including Waxing/Polishing of Floors or Walls FORMCHECKBOX Residential cleaning FORMCHECKBOX Pool cleaning FORMCHECKBOX Sweeping of Parking Lots FORMCHECKBOX Other: FORMTEXT ?????Does the insured perform any of the following operations: FORMCHECKBOX Exterior Window Cleaning FORMCHECKBOX Cleaning of health care or industrial facilities FORMCHECKBOX Carpet Cleaning FORMCHECKBOX Crime scene or Bio-Hazard clean-up FORMCHECKBOX Mobile Power / Pressure Washing services FORMCHECKBOX Graffiti removal FORMCHECKBOX Water or fire damage restoration FORMCHECKBOX Chimney cleaning from the roof FORMCHECKBOX Pest Control FORMCHECKBOX Aluminum Nitrate handling FORMCHECKBOX Fire Extinguisher refilling, service or repair 3. Do they have on-site cleaning equipment and supplies? FORMCHECKBOX Yes FORMCHECKBOX No What is the number of building the majority of your crew(s) service per shift: FORMCHECKBOX 1 Building FORMCHECKBOX 2-3 Buildings FORMCHECKBOX 3 or more buildings5. Does the insured have Independent Contractors or 1099 Employees? FORMCHECKBOX Yes FORMCHECKBOX No6. Employees supervised? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, supervision is: FORMCHECKBOX Direct FORMCHECKBOX RovingDo employees work in pairs or more? FORMCHECKBOX Yes FORMCHECKBOX No7. Any group transportation of employees? FORMCHECKBOX Yes FORMCHECKBOX No LANDSCAPINGDoes the insured perform any of the following operations: FORMCHECKBOX Weed abatement FORMCHECKBOX Above ground level tree trimming FORMCHECKBOX More than incidental excavation work FORMCHECKBOX Clearing of land and/or debris FORMCHECKBOX Habitat restoration FORMCHECKBOX Set-up of holiday decorations FORMCHECKBOX Erosion control FORMCHECKBOX Removal of parasitic vines like mistletoe FORMCHECKBOX Tree planting greater than 15 gallons FORMCHECKBOX Tree removal FORMCHECKBOX Sprinkler installation FORMCHECKBOX Any work that required excavation or trenching below 6’ FORMCHECKBOX Work along non-residential medians or major roads/highways2.Does the insured hire “Day Laborers”? FORMCHECKBOX Yes FORMCHECKBOX No3. Percentage of operations that apply to insured:Mow and Bow: FORMTEXT ???%Landscape Design: FORMTEXT ???%Hydro Mulch: FORMTEXT ???%Do the insured’s operations include snow removal? FORMCHECKBOX Yes FORMCHECKBOX Less than 10% FORMCHECKBOX More than 10% FORMCHECKBOX NoIf yes, does the insured perform any snow removal from rooftops? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the insured install artificial turf? FORMCHECKBOX Yes FORMCHECKBOX NoWhat percentage of the risk's operations are: Residential FORMTEXT ???% New FORMTEXT ???%Remodel FORMTEXT ???% Commercial FORMTEXT ???% New FORMTEXT ???%Remodel FORMTEXT ???%Does the insured do hardscape work? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, % of the following operations:Concrete or Masonry Work FORMTEXT ???%Retaining walls FORMTEXT ???%Swimming pools/spas FORMTEXT ???%Waterfalls / ponds FORMTEXT ???%Fences FORMTEXT ???%Decks FORMTEXT ???%Any use of chippers, mulchers, cherry pickers, booms or other similar equipment? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes above, please explain: FORMTEXT ?????What % of operations involves landscape work on green buildings (rooftops, sides of buildings)? FORMTEXT ???% MANUFACTURINGProvide a brief description of the product manufactured: FORMTEXT ?????What is the weight of the insured’s finished product (Please select only one option)? FORMCHECKBOX Less than 5 lbs. FORMCHECKBOX 6 lbs. to 25 lbs. FORMCHECKBOX 26 lbs. to 50 lbs. FORMCHECKBOX Greater than 50 lbs.Is 51% or more of the insured’s product produced via a Computer Pneumatic Controlled machine or a CAD / CAM machine? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the insured have assembly operations? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, does the insured have job rotation? FORMCHECKBOX Yes FORMCHECKBOX NoWhat types and percentage of raw materials does the insured use? FORMCHECKBOX Plastics FORMTEXT ???% FORMCHECKBOX Aluminum FORMTEXT ???% FORMCHECKBOX Titanium FORMTEXT ???% FORMCHECKBOX Zinc FORMTEXT ???% FORMCHECKBOX Magnesium FORMTEXT ???% FORMCHECKBOX Copper FORMTEXT ???% FORMCHECKBOX Cadmium FORMTEXT ???% FORMCHECKBOX Brass FORMTEXT ???% FORMCHECKBOX Lead FORMTEXT ???% FORMCHECKBOX Nickel FORMTEXT ???% FORMCHECKBOX Chromium FORMTEXT ???% FORMCHECKBOX Tin FORMTEXT ???% FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ???% How many of each type of machine shown below are used?CNC# FORMTEXT ?????Planer# FORMTEXT ????? Milling# FORMTEXT ?????Boring# FORMTEXT ?????Stamping# FORMTEXT ?????Drilling# FORMTEXT ?????Power Presses# FORMTEXT ?????Grinders# FORMTEXT ?????Cutters# FORMTEXT ?????Saws# FORMTEXT ?????Welding# FORMTEXT ?????Sandblasting# FORMTEXT ?????Die Casting# FORMTEXT ?????Press Brakes # FORMTEXT ?????Jig Borer# FORMTEXT ?????Lathes# FORMTEXT ?????Punch Press# FORMTEXT ?????Other (type and number): FORMTEXT ????? # FORMTEXT ????? 6. Who is responsible for maintaining machinery? FORMCHECKBOX Insured FORMCHECKBOX Contractor FORMCHECKBOX Other: FORMTEXT ????? 7. Does the insured do any installation? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ????? 8. Is there any off premises work? FORMCHECKBOX Yes FORMCHECKBOX Noif Yes, what percentage: FORMTEXT ???%If yes, what are these operations & where? FORMTEXT ????? 9. Any interchange of labor? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ????? 10. Age of machinery: FORMCHECKBOX <2 years FORMCHECKBOX 2-5 years FORMCHECKBOX 5-10 years FORMCHECKBOX 10+ years11. Accessible moving parts guarded on machinery/equipment? FORMCHECKBOX Yes FORMCHECKBOX No 12. Is building properly ventilated? FORMCHECKBOX Yes FORMCHECKBOX NoIs proper dust collection system in place? FORMCHECKBOX Yes FORMCHECKBOX NoHOTEL / MOTELWhich of the following best describes the risk's operations? FORMCHECKBOX HotelRating: FORMDROPDOWN FORMCHECKBOX Hotel/CasinoRating: FORMDROPDOWN FORMCHECKBOX MotelRating: FORMDROPDOWN FORMCHECKBOX Bed & Breakfast Rating: FORMDROPDOWN FORMCHECKBOX TimeshareBrand Name: FORMTEXT ????? FORMCHECKBOX Fraternity/Sorority House FORMCHECKBOX Boarding House FORMCHECKBOX Dude Ranch FORMCHECKBOX Hostel FORMCHECKBOX Brothel Does the insured rent their rooms by the hour? FORMCHECKBOX Yes FORMCHECKBOX No Does the insured use sub-contractors for their major repairs? FORMCHECKBOX Yes FORMCHECKBOX No4. Does the insured provide shuttle service? FORMCHECKBOX Yes FORMCHECKBOX No5. Do they have the ability to store their cleaning equipment on each floor? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, do they have access to an elevator? FORMCHECKBOX Yes FORMCHECKBOX No RESTAURANTSWhat type of restaurant best describes the insured’s operations? (Check all that apply) FORMCHECKBOX Fine Dining (Entrée Price $20 or >) FORMCHECKBOX Casual Dining/Family Style FORMCHECKBOX Diner (IHOP/Denny’s, etc.) FORMCHECKBOX Banquet Hall FORMCHECKBOX Cafeteria/Buffet FORMCHECKBOX Hotel/Resort Restaurant FORMCHECKBOX Fast Food FORMCHECKBOX Pizza Delivery FORMCHECKBOX Mobile Catering Truck FORMCHECKBOX Tavern/Sports Bar FORMCHECKBOX Gentleman’s Club FORMCHECKBOX Night Club 2. Does the insured do any off-site catering (delivery and set-up of food)? FORMCHECKBOX Yes FORMCHECKBOX No 3. Does the insured have entertainment? FORMCHECKBOX Yes FORMCHECKBOX No 4. Does the insured have security guards or bouncers? FORMCHECKBOX Yes FORMCHECKBOX No 5. Are any of the insured’s locations open after 11 pm? FORMCHECKBOX Yes FORMCHECKBOX No 6. Does the insured require non-slip shoes? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is this a “Shoes for Crews” program? FORMCHECKBOX Yes FORMCHECKBOX No7. What is the percentage of liquor sales? FORMTEXT ???%RETAIL / WHOLESALE1. Type of Merchandise? FORMTEXT ????? 2. Gross Receipts: $ FORMTEXT ?????Wholesale FORMTEXT ???% Retail FORMTEXT ???%Warehousing? FORMCHECKBOX Yes FORMCHECKBOX No3. Does the insured have repackaging or assembly operations? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain operations: FORMTEXT ????? ................
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