Workers Compensation Insurance Application Social Services "*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.First Named Insured*DBAMailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell phone number*Email address* Facility license numberFEINEffective date MM slash DD slash YYYY Retro date MM slash DD slash YYYY Prior carrier namePrior premium$Operations:Is license pending? Yes No Is operation accredited by CARF? Yes No Are owners active in daily operations? Yes No Group health coverage provided? Yes No Return to work program in place? Yes No Check all hiring practices Written Application Reference checks Criminal Background checks Pre Hire Drug Testing Random Drug Testing Post Accident Drug Testing Pre Hire MVR Reports Physicals Orthopedic Back Testing Is job specific training provided? Formal Written Informal Verbal None Employee Orientation Yes No Are there set procedures for reporting claims? Yes No Do you have a formal written accident report? Yes No Is Group Transportan provided? Yes No Number of company vehiclesNumber of Personal VehiclesPercentage of group transportation subcontracted Yes None How many %Does the insured’s vehicle have liftgate? Yes No Any off-site activities? Yes No How often Weekly Monthly Quarterly Annually Does your IIPP (SB198) address the following specific Healthcare related exposures? Patient handling? Yes No Lifting exposures? Yes No How much <25lbs 26-40lbs >40lbs Aggressive combative exposures? Yes No Does the insured have two years prior coverage? Yes No If not, is the insured a new venture? Yes No If a new venture, are you associated with a church? Yes No Is the insured a purchase of an existing operation? Yes No Please provide detailsList all personal protective equipment Gloves Back Belts Protective clothing Masks Other The undersigned acknowledges and understands the information provided herein will be used to evaluate the applicant and a decision as to whether the applied to insurance company will offer workers’ compensation insurance will be made, in part, based on the information provided. The signature below indicates the information provided is true and correct. This Supplemental Application must be signed by a principle, owner or partner of the entity applying for insurance.Owner/Officer SignatureDate MM slash DD slash YYYY Untitled* I acknowledge and agree to submit this information
