Workers Compensation Quote

Contact Information
Insured *
Contact Name *
Contact Title
Effective Date
FEIN No.
Telephone No.
Fax No.
Insured History
Years in Business
If less than 5, Years in Trade
No. of Locations
Description of Operations
Out of State Exposure? Yes  No
If Yes than Name of States:
Foreign Travel Yes  No
Number of Employees
Number of Employees
  Full-time Part-time Seasonal Volunteers
Percent Employee Turnover
Percent Employee Turnover
  Full-time Part-time
Percent of turn over in last 12 months:
Employee staffing expectation over the next 12 months:
Wages
Wages
Average Hourly Wage, Full-time:
Average Hourly Wage, Part-time:
Any Piece Work Compensation:
Benefits provided- Are ALL employees eligable? Yes  No
If No than who is eligable?
Benefits
Benefits
  % paid by employer % of participation
Group Health Yes  No
Paid sick leave Yes  No
Vacation Yes  No
Retirement/Pension Plan Yes  No
Healthcare
Name of Healthcare Provider:
Name of clinic, physician, or emergency room used for a work place related injury:
Yes  No
CPR training provided? Yes  No
Safety Activities
Indicate the safety activities currently established and practiced regularly.
Is Owner active in daily operations? Yes  No
If Yes, duties performed:
Safety program/ IIPP in use compliant with SB198? Yes  No
Return to light duty plan? Yes  No
Light duty: includes full wages? Yes  No
Return to Full-time modified work plan? Yes  No
Full-time safety director? Yes  No
If Yes, safety director's name:
Safety meeting held for all employees? Yes  No
Frequency of safety meetings:
Safety training held for all employees? Yes  No
Safety incentive program for all employees? Yes  No
Slip and Fall Prevention Program in place? Yes  No
Hazardous Materials Communication program in place? Yes  No
Personal Protective safety equipment provided for employees? Yes  No
If Yes, what type?
Supervisors held accountable for accidents/injuries? Yes  No
Accident investigation program in place? Yes  No
Hiring Practices
Employment application? Yes  No
Reference checks? Yes  No
Motor Vehicle Records check? Yes  No
Volunteer labor used? Yes  No
Temporary labor used? Yes  No
Drug/substance abuse screening? Yes  No
Audiometric testing? Yes  No
Pre/Post employment physical? Yes  No
Pathogenic test (i.e. lead)? Yes  No
Orthopedic back test? Yes  No
Operations
Hours of operation?
No. of daily shifts?
No. of days per week?
Operation includes delivery? Yes  No
No. of authorized drivers?
No. of vehicles?
Frequency of delivery: Daily  Weekly  Other
Delivery radius: <50 miles  51-100 miles  101-250 miles  >250 miles
Frequency of MVR checks:
Participation in CHP Pull Program? Yes  No
Driver acceptability standards have been established? Yes  No
Vehicle inspection/maintenance program? Yes  No
If Yes, frequency of inspection/maintenance:
Vehicle maintenance is performed by employees? Yes  No
Employees take vehicles home at night? Yes  No
Exposure Information
Premises - Fixed Location - Employees
  State Location # Payroll Total # of Employees # of Shifts Max. # of Employees per Shift Building Type Year Built # of Stories Floors Occupied
Payroll and Premium History
  Payroll Premium
Current Year:
1st Prior Year
2nd Prior Year
3rd Prior Year
* = Required Field
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