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ASAC PACKAGE POLICY APPLICATIONSubmitting Broker: FORMTEXT Athlon Risk Insurance ServicesP.O. Box 957, Placentia CA 92871Placentia, CA 92871 FORMTEXT (714) 602-1162/(714) 876-9216 faxName (First Named Insured and other Named Insureds)Mailing Address (First Named Insured Only)Is applicant involved in any other business? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” explain:Type of Business:Nature of Operation:Effective DateExpiration DateBusiness Phone Number:Fax Phone Number:E-Mail:Type of Operation:Years in Business: FORMCHECKBOX Franchisee FORMCHECKBOX FranchisorIf Franchisee or Franchisor, provide copy of contract FORMCHECKBOX Independent FORMCHECKBOX Other (Describe): OWNER/OFFICER INFORMATIONNameTitlePercentage of OwnershipDate of BirthHome Phone NumberActive in Business?UNDERWRITING SECTION (Complete this Section for each state the company does business)State:Annual SalesAnnual PayrollW-2’s1099’s# of Hours# of FT EmployeesRecruiters &ConsultantsTemporary StaffingMedical StaffingEmployee LeasingHome Care OnlyIndustrial Day PayEmployment AgencyTotal:CLASS OF BUSINESS: This includes all employees who are leased or placed as temporary employees by the insuredCLASSPAYROLLCLASSPAYROLLClericalArchitects/Non-Software EngineersBank TellersSecurity GuardsLight IndustrialProgrammersDrivers/TransportationAccountantsHeavy Industrial and ConstructionMedical (RN/LVN/CNA/etc.)ParalegalMedical (Clerical)AttorneyOther: STATESState:Annual SalesAnnual PayrollW2’s1099’s# of Hours# of FT EmployeesRecruiters &ConsultantsTemporary StaffingN/AMedical StaffingHome Care OnlyEmployment AgencyN/ATotal:State:Annual SalesAnnual PayrollW2’s1099’s# of Hours# of FT EmployeesRecruiters &ConsultantsTemporary StaffingN/AMedical StaffingHome Care OnlyEmployment AgencyN/ATotal:State:Annual SalesAnnual PayrollW2’s1099’s# of Hours# of FT EmployeesRecruiters &ConsultantsTemporary StaffingN/AMedical StaffingHome Care OnlyEmployment AgencyN/ATotal:State:Annual SalesAnnual PayrollW2’s1099’s# of Hours# of FT EmployeesRecruiters &ConsultantsTemporary StaffingN/AMedical StaffingHome Care OnlyEmployment AgencyN/ATotal:State:Annual SalesAnnual PayrollW2’s1099’s# of Hours# of FT EmployeesRecruiters &ConsultantsTemporary StaffingN/AMedical StaffingHome Care OnlyEmployment AgencyN/ATotal:State:Annual SalesAnnual PayrollW2’s1099’s# of Hours# of FT EmployeesRecruiters &ConsultantsTemporary StaffingN/AMedical StaffingHome Care OnlyEmployment AgencyN/ATotal:State:Annual SalesAnnual PayrollW2’s1099’s# of Hours# of FT EmployeesRecruiters &ConsultantsTemporary StaffingN/AMedical StaffingHome Care OnlyEmployment AgencyN/ATotal:GENERAL INFORMATION: This section is required for all employersDo you conduct background checks on all job applicants/employees? FORMCHECKBOX Yes, All employees FORMCHECKBOX Money handlers only FORMCHECKBOX Upon Client Request only FORMCHECKBOX NoDo you check the references for all job applicants/employees? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” how are they checked? FORMCHECKBOX Verbal FORMCHECKBOX Written FORMCHECKBOX BothIf you do not request and check references, please explain why:Do you question prospective employees as to any criminal record? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” how are they checked? Do you verify certification and/or professional licensing status of employees that require a City or State License? FORMCHECKBOX Yes FORMCHECKBOX NoAre job descriptions provided for all professional employees?Are job descriptions provided for non-professional employees? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDoes applicant obtain risk management services from an outside company? FORMCHECKBOX Yes FORMCHECKBOX NoDo you back up software and data files?Is backup media/software stored at a separate location? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes”, how often: FORMCHECKBOX Yes FORMCHECKBOX NoDo you have any owned autos?Owned auto carrierPolicy NumberExp. DateLimits FORMCHECKBOX Yes FORMCHECKBOX NoHow many?: FORMTEXT ?????Do you provide transportation to the job? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” please explain: FORMTEXT ?????Do you place Temp Drivers or Temp Employees where their primary responsibility is driving? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” please explain: FORMTEXT ?????Do you make any temporary placement where the employee would travel or live outside of the United States? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” how manyAvg. assignment durationEst. Payroll:Countries:Do you pay daily or weekly? FORMCHECKBOX Daily FORMCHECKBOX Weekly FORMCHECKBOX Other:Do you have a standard contract you use? (Required for PEOs/Employee Leasing Operations) FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” please provide a copy. Do you sign Hold Harmless Agreements? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” provide copies of those that have been signed. Do you obtain a Waiver, Hold Harmless or Indemnification Agreement from client companies which absolve you from any liability for claims resulting from the operation of any Fixed Machinery or Mobile Equipment such as Forklifts, Golf Carts, and Floor Sweepers? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” provide copies of those that have been signed.Additional Insured Requests:If you have clients that request Additional Insured Endorsements, a copy of the contract, temp job duties, number of temps placed, assignment length, who is providing direct supervision of the temps, estimated annual revenue and payroll of each specific contract for all Additional Insured requested must be provided before the Additional Insured Endorsement will be issued.CURRENT POLICY INFORMATIONCurrent CoverageInsurance CarrierLimits of LiabilityDeductibleExpiration DateAnnual PremiumGeneral LiabilityPropertyHired/Non Owned AutoFidelity BondErrors & OmissionsProvide 3 years of currently valued (90 days or less before policy renewal) loss runs from prior carriers.Industry Specific Questions (Complete Applicable Sections Below)INDUSTRIAL & CONSTRUCTION QUESTIONNAIREDo you place any of the following? FORMCHECKBOX Heavy Equipment Operators FORMCHECKBOX Chemical Manufacturer FORMCHECKBOX Construction Work FORMCHECKBOX Other:ATTORNEY QUESTIONNAIREWhat types of placements do you make? FORMCHECKBOX Insurance Claims FORMCHECKBOX Research FORMCHECKBOX Trial FORMCHECKBOX Sec Work FORMCHECKBOX Personal Injury FORMCHECKBOX Other:Have you confirmed all Attorney Applicants are currently licensed and no disciplinary action pending? FORMCHECKBOX Yes FORMCHECKBOX NoDo any attorneys you place have final sign-off authority? FORMCHECKBOX Yes FORMCHECKBOX NoDo you use contracts? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” please attach a copy to this application.PROGRAMMER QUESTIONNAIREWhat types of program applications are done for clients? FORMCHECKBOX Accounting FORMCHECKBOX Inventory FORMCHECKBOX Scientific FORMCHECKBOX Medical FORMCHECKBOX Engineering FORMCHECKBOX Other:Do you use contracts? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” please provide a copy.ENGINEERS QUESTIONNAIREWhat type of engineers do you place? (If you place temporary employees in any category, please provide specific job functions.) FORMCHECKBOX Aerospace FORMCHECKBOX Electrical FORMCHECKBOX Mechanical FORMCHECKBOX Computer Software FORMCHECKBOX Other:Do any architects or engineers you place have final sign-off authority? FORMCHECKBOX Yes FORMCHECKBOX NoDo you use contracts? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” attach a copy to this application.Do you sign Hold Harmless Agreements? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” send copies of those signed.ACCOUNTANTS QUESTIONNAIREWhat type of accounting position do you fill? FORMCHECKBOX General FORMCHECKBOX Auditing FORMCHECKBOX Tax Work FORMCHECKBOX SEC Work FORMCHECKBOX Consulting FORMCHECKBOX Other: FORMTEXT ?????Do any accountants you place have final sign-off authority? FORMCHECKBOX Yes FORMCHECKBOX NoBANK TELLERS/MONEY HANDLING POSITIONS QUESTIONNAIREDo place any bank tellers or money handlers? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes” to the question above, do you perform background checks? (Required for Bond and Errors & Omissions coverage) FORMCHECKBOX Yes FORMCHECKBOX NoADDITIONAL NOTES(If there is more than one location, DUPLICATE this page and complete one for each location)PROPERTY SECTIONLocation NumberAddressCountyConstruction Type:Prot. Class:# Stories:Yr Built:Area Occupied:Employment Agency Area:Other Occupancies:sq. ft.sq. ft.Burglar Alarm:Dead Bolts:Fire Protection: FORMCHECKBOX Yes FORMCHECKBOX No If “Yes”: FORMCHECKBOX Central FORMCHECKBOX Local FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No If “Yes”: FORMCHECKBOX Central Building Improvements (Complete if building is over 40 years old)Florida Only (Coastal Properties)Wiring-Year Completed:Plumbing-Year Completed:Distance from water:Heating-Year Completed:Roofing-Year Completed:Other: Year Completed:Property CoveragesDesired LimitsDeductibleCo-Ins. %FormBuilding$ FORMTEXT ???%SpecialOffice Contents Incl. Tenant Improvements$90% Agreed AmtReplacement CostSpecialProperty of Others (CCC Coverage-Optional)$Incl.N/AProperty of OtherProperty of Others (Replaces Fire Legal Liability)$Incl.N/ALegal LiabilityBusiness Income and Extra Expense$Incl.N/ASpecial Form120 DaysInland Marine CoveragesDesired LimitsDeductibleCo-Ins. %FormValuable Papers$N/AInland MarineAccounts Receivable$Incl.N/AInland MarineComputer Hardware Incl. Phone. Sys & Lap Top*$Incl.N/AEDPLap Tops (must be scheduled)*$N/AEDPComputer Software/Media$Incl.N/AEDPComputer Extra Expense$Incl.N/AEDPComputer Business Interruption$Incl.N/AEDPComputer Power Outage- -Eliminates Dist. Limit$Incl.N/AInland MarineComputer in Transit (DOESN’T INCLUDE LAP TOPS)$Incl.N/AEDPMiscellaneous CoveragesDesired LimitsDeductibleCo-Ins. %FormFine Arts Floater$ FORMTEXT Use Accord AppInland MarineGlass CoverageInterior:Exterior:$ FORMTEXT Use Accord AppPropertySign Coverage$ FORMTEXT Use Accord AppInland MarineRemarks (*Lap Tops must be scheduled including serial # and value):Make: Model: Serial #: Value: COMMERCIAL GENERAL LIABILITY SECTIONPolicy Type:Deductibles: FORMCHECKBOX Claims Made FORMCHECKBOX OccurrenceBodily Injury:$ FORMTEXT NoneProperty Damage:$ FORMTEXT NoneCoveragesLimitsGeneral AggregateProducts and Completed Operations AggregatePersonal and Advertising InjuryEach OccurrenceFire Legal Liability (covered under property section legal liability form CP213)Medical Expense - Any One PersonOwners & Contractors ProtectiveOPTIONAL COVERAGEEmployee Benefit Liability* - ($1000 Deductible) FORMCHECKBOX Yes FORMCHECKBOX NoCSLHired and Non Owned Automobile Liability FORMCHECKBOX Yes FORMCHECKBOX NoCSLStop Gap Coverage for Monopolistic W/C States only FORMCHECKBOX Yes FORMCHECKBOX No$1MM/1MM/1MMIf “Yes” – list Total Payroll in each Monopolistic State:OH$ WA$ WY$ WV$ ND$ *Employee Benefit Liability for temporary staffing firms and employment agencies only covers full-time employees, unless benefits are provided to the temps. Employee Benefit Liability for employee leasing firms and contract temporary help firms covers all employees.ERRORS & OMISSIONS SECTIONQuote:Temporary Help Service FORMCHECKBOX Yes FORMCHECKBOX NoPersonnel Consultants FORMCHECKBOX Yes FORMCHECKBOX NoLimitsIncreased LimitsEach OccurrenceGeneral AggregateDeductibleFIDELITY BOND SECTIONCrime CoverageLimitsDeductiblesI.A.Insured’s Fidelity CoverageB.Client’s Fidelity CoverageC.Legal Liability Fidelity CoverageII.Trade Secret Fidelity CoverageIII.Depositor’s Forgery CoverageIV.Credit Card Forgery puter Crime CoverageVI.Theft InsideVII.Theft OutsideDo you have an employee welfare or pension plan? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” name of plan: Number of TrusteesAmount of Bond Needed# of Employees Covered by Benefit PlansCLAIMS INFORMATIONHave you had a loss in the past five (5) years for: FORMCHECKBOX Property FORMCHECKBOX Liability FORMCHECKBOX Fidelity Bond FORMCHECKBOX Excess Liability FORMCHECKBOX E & O FORMCHECKBOX Hired/NOA FORMCHECKBOX Owned Auto FORMCHECKBOX OtherDo you have knowledge or information regarding an incident that can reasonably be expected to turn into a claim? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” please attach an explanation?UMBRELLA APPLICATIONTo be used when limit of liability is under $5,000,000 – Over $5,000,000 requires Acord FormApplicant Name:DateEffective Date:Expiration Date:Annual Payroll:Annual Gross Sales:Annual W-2 Count:# of Full-Time Employees:Policy Information:Expiring Policy Number:Transaction Type FORMCHECKBOX New FORMCHECKBOX RenewalProposed Retroactive Date:Current Retroactive Date:Limit of Liability:Retained Limit:Each OccurrenceUNDERLYING INSURANCE INFO: List all in force liability/compensation policies to apply as underlying insuranceTYPECOVERAGECARRIER/POLICYNUMBERPOLICY EFFECTIVEDATEPOLICY EXPIRATIONDATELIMITSANNUAL RENEWALPREMIUMOwned AutoLiabilityCSL$Non-Owned & HiredAuto LiabilityCSL$BI/PD$CSL$General Liability FORMCHECKBOX OccurrenceGeneral Aggregate$Prem/Ops Products/Completed Ops$Products Aggregate$Personal Injury/Adv$Other Fire Damage$Medical Expense$Employers LiabilityEach Accident$Disease Policy Limit$Disease Each Employee$Errors & OmissionsMedical MalpracticeCSL$UNDERLYING GENERAL LIABILITY INFORMATION1.Are defense costs FORMCHECKBOX within aggregate limits FORMCHECKBOX separate limit FORMCHECKBOX unlimited2.Indicate the edition date of the ISO Simplified Form or Similar filing for the Underlying Coverage: FORMTEXT 11/853.For Claims Made was “Tail” coverage purchased for any previous primary or excess policy? FORMCHECKBOX Yes FORMCHECKBOX NoEffective Date:CHECK ALL COVERAGES IN UNDERLYING POLICIES, ALSO CHECK IF ANY EXPOSURES ARE PRESENT FOR EACH COVERAGECheck if Appropriate FORMCHECKBOX Any Auto (Symbol 1) FORMCHECKBOX CGL – Claims Made Form FORMCHECKBOX CGL – Occurrence FormCoverageExposure FORMCHECKBOX Additional Insured’s FORMCHECKBOX FORMCHECKBOX Care, Custody, Control (CCC) FORMCHECKBOX FORMCHECKBOX Employee Benefit Liability FORMCHECKBOX FORMCHECKBOX Incidental Medical Malpractice FORMCHECKBOX CoverageExposure FORMCHECKBOX Host Liquor Liability FORMCHECKBOX FORMCHECKBOX Professional Liability/Errors & Omissions FORMCHECKBOX FORMCHECKBOX Watercraft Liability FORMCHECKBOX AUTOVEHICLE TYPE# Owned# Non-Owned# Leased1.Are passengers carried for a fee? FORMCHECKBOX Yes FORMCHECKBOX No2.Are units not insured by underlying policies? FORMCHECKBOX Yes FORMCHECKBOX No3.Are any vehicles leased or rented to others? FORMCHECKBOX Yes FORMCHECKBOX No4.Are Hired & Non-Owned coverages provided? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Private Passenger FORMCHECKBOX Trucks: FORMCHECKBOX Light FORMCHECKBOX Medium FORMCHECKBOX HeavyEMPLOYERS LIABILITYIs applicant Self-Insured in any State?Subject to: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Jones Act FORMCHECKBOX FELA FORMCHECKBOX Stop GapState for Stop Gap: FORMTEXT ?????APPLICABLE ONLY IN LOUISIANA, NEW MEXICO, OHIO, TENNESSEE AND VERMONT:I acknowledge that uninsured motorist (UM) coverage has been explained to me, and I have been offered the option of selection UM limits equal to my liability limits, UM limits lower than my liability limits or to reject UM coverage entirely.I select umbrella limits indicated in this applicationI reject umbrella coverage in its entirety(Sign)(Sign)IMPORTANT: The statements (answers) given above are true and accurate. The applicant has not willfully concealed or misrepresented any material fact or circumstance concerning this application. Applicant understands this application does not constitute a binderApplicant Signature:DateMISCELLANEOUSProfessional type employees: (e.g., Architects, Engineers, Programmers, Accountants, Attorneys)I understand that there is no coverage if the professionals I place render a final opinion or sign off on a project. I further agree not to place employees of the above type in a job of authority; all will be under the client’s supervision. Also, for the above professional employees, I have not and will not sign a hold harmless agreement with any client.Additional Insured’s/Hold Harmless AgreementThe risk factor of a temporary staffing firm is generally a secondary type of exposure and is priced as such. When you request a client to be added on as an Additional Insured or you sign a Hold Harmless agreement, this puts the insurance company in the primary position in taking risk. The program is not designed to be the primary risk taker nor is it priced to be Primary; therefore, getting Additional Insured endorsements for clients can be very difficult, especially if the job calls for the temporary employee to be working in an area that has your insurance carrier in the primary position for products/completed operations coverage. All technical firms with engineers where they have sign off authority or you have signed a Hold Harmless agreement are very difficult to get done.Various state required statementsThis application does not bind the applicant to buy, or the company to issue, the insurance, but it is agreed that this application shall be the basis of the contract should a policy be issued. The applicant declares that the statements set forth in this application are true to the best of his/her knowledge and belief, after reasonable inquiry. The applicant further declares that if the information supplied on this application changes between the date of this application and the time when the policy is issued, the applicant will immediately notify the company of such changes. Depending on the changes made, the company may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance.Notice to Arkansas, Minnesota, and Ohio Applicants: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud, which is a crime.Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.Notice to Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim or an application containing any false or misleading information is guilty of a felony of the third degree.Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.Notice to Maine and Virginia Applicants: It is unlawful to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.Notice to Maryland Applicants: Any person who, with intent to defraud or knowing that he/she is facilitation a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.Notice to Oklahoma Applicants: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony.Notice to Oregon & Texas Applicants: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.NOTE: I understand there is no coverage for Laptop Computers unless they are scheduled.All property values submitted and shown in the application by address are correct to the best of my knowledge for the agreed amount endorsement and represent values to be at least 100% to value. I have read and agree to the limits used on the business income and extra expense, accounts receivable and valuable papers coverage. I will provide any changes in value in writing.Applicant’s Name:Title:Applicant’s Signature:Date:Submitting Agent’s Name: ................
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