Insured:

Eff Date:

FEIN NO:

Contact Name & Title:

Tel. No:

Fax No:

INSURED HISTORY:

Years in business:

No. of locations

Description of Operations

Out of state exposure:

Yes

No

If yes, name of states:

Foreign Travel:

Yes

No

Present number of employees:

Full-time employees

Part-time

Seasonal

Volunteers

Percent of employee turnover in the last 12 months (Full Time)

Percent of employee turnover in the last 12 months (Part Time)

Employee staffing expectation over the next 12 months (Full Time)

Employee staffing expectation over the next 12 months (Part Time)

Average hourly wage: (Full Time $)

Average hourly wage: (Part Time $)

Any Piece work compensation:

Benefits provided, are all employees eligible?

Yes

No

If not then who is eligible?

Group Health

Yes

No

Paid sick leave

Yes

No

Vacation

Yes

No

Retirement / Pension Plan

Yes

No

Name of Healthcare provider:

Provide name of clinic, physician, or emergency room used for work place related injury:

Full-time nurse maintained on staff:

Yes

No

CPR training provided

Yes

No

INSURED HISTORY:

Indicate the safety activities currently established and practiced regularly

HIRING PRACTICES:

OPERATIONS:

PAYROLL HISTORY:

PREMIUM HISTORY:

CATASTROPHE EXPOSURE:

MEDICAL PROVIDER NETWORK COMPLIANCE:

THIS FORM MUST BE FILLED OUT IF IT APPLIES TO THE INSURED

HOTEL / MOTEL:

RETAIL / WHOLESALE:

MANUFACTURING:

SERVICE STATIONS / AUTO REPAIR SHOPS / TRANSMISSION SHOPS:

ATTORNEYS:

RESTAURANT:

APARTMENT OWNER OR OPERATOR:

CONTRACTORS:

FARMS:

TRUCKING EXPOSURES:

Reinsurance Information:

Recents Articles

The Importance of Long-Term Care Insurance in Future Planning

Why Health Insurance is Essential for Every Business Owner and Their Employees

April Insurance Agency

Get A Quote

Helpful Links

For Clients

Maverick WC Insurance Quote

INSURED HISTORY:

Indicate the safety activities currently established and practiced regularly

HIRING PRACTICES:

OPERATIONS:

PAYROLL HISTORY:

PREMIUM HISTORY:

CATASTROPHE EXPOSURE:

MEDICAL PROVIDER NETWORK COMPLIANCE:

***THIS FORM MUST BE FILLED OUT IF IT APPLIES TO THE INSURED***

HOTEL / MOTEL:

RETAIL / WHOLESALE:

MANUFACTURING:

SERVICE STATIONS / AUTO REPAIR SHOPS / TRANSMISSION SHOPS:

ATTORNEYS:

RESTAURANT:

APARTMENT OWNER OR OPERATOR:

CONTRACTORS:

FARMS:

TRUCKING EXPOSURES:

Reinsurance Information:

Recents Articles

The Importance of Long-Term Care Insurance in Future Planning

Why Health Insurance is Essential for Every Business Owner and Their Employees

April Insurance Agency

Get A Quote

Helpful Links

For Clients

THIS FORM MUST BE FILLED OUT IF IT APPLIES TO THE INSURED