If more than 20 employees are working at any given time at a single location, what year was the building built?

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1 GENERAL INFORMATION Legal Name of Company: Legal Entity: DBA: Tax ID #: Location Address(es): If more than 20 employees are working at any given time at a single location, what year was the building built? Has the building been retrofitted for an earthquake? Yes No Owners On Payroll Exclude Detailed Description of Operations: Website: Years in Business: Primary Contact & Phone Number: General Questions 1. Is the company a subsidiary of another entity or have any subsidiaries? Yes No 2. Is there exposure to flammables, explosives, or chemicals in the company operations? Yes No If yes, describe protection and preventative measures used: 3. What percentage of the company s revenue, past or present, is involved with Owner Controlled Insurance Programs (OCIP)? 4. Has the company ever had an employee, present or terminated, file a charge of discrimination, Yes No a wage and hour claim, or any other complaint against the company with a government agency? 1

2 5. Does the company have any employees covered under a collective bargaining agreement or are Yes No any current union organizing activities underway? 6. Does the company pay overtime (time and a half) for non-exempt employees who work more Yes No than 40 hours per week? 7. What is the average length of employment in months? 8. What is the percentage of turnover in the company s workforce each year? 9. How many of the company s employees are supervisors? WO R K E R S CO M P E N S AT I O N Workers Comp Class Code or Employee Duties # of FT # of PT Annual Payroll 10. What is your current workers comp Experience Modification? 11. Proposed (or desired) e ective date of coverage? 12. Will you require a Waiver of Subrogation for any Certificate holders? (Waiver of Subrogation Yes No fee is $250.) 13. Does the company own, operate or lease any aircraft or watercraft? Yes No 14. Has the company s past, present, or discontinued operations included storing, treating, Yes No discharging, applying, disposing, or transporting of hazardous material (e.g. landfills, wastes, fuel tanks, etc.)? 15. What percent of the company s work is performed underground? 16. What is the Maximum Depth the company s work is underground? (in feet) 17. Does your company perform any work above ground level? Yes No 18. What percent of the company s work is above 15 feet? Please describe situations: 19. What is the maximum height the company s work is above 15 feet? (in feet) 2

3 20. Does the company perform work on barges, vessels, docks, or bridges over water? Yes No 21. Are you engaged in any other type of business? Yes No 22. What percentage of work is done by subcontractors? 23. What is the average number of subcontractors used by the company? 24. Describe work performed by subcontractors used by the company: 25. Is there any work for the company sublet without certificates or insurance? Yes No 26. How many of the company s subcontractors work without documented workers compensation coverage? 27. Are any of the company s subcontractors on exemption forms? Yes No 28. Does the company enforce a written safety program? Please explain: Yes No 29. Does the company provide group transportation? Yes No 30. How many of the company s employees are under the age of 16? 31. How many of the company s employees are over the age of 60? 32. What percentage of the company s employees are employed as seasonal workers? 33. What percentage of the company s employees are migrant workers? 34. Does the company use any volunteer or donated labor? Yes No 35. Does the company have any employees with physical handicaps? Yes No 36. Does the company o er an employee health plan? Yes No 37. How many vehicles are owned or leased by the company? 38. What types of vehicles are owned by the company? 39. What percentage of the company s employees work o its premises? 40. Do the company s employees travel out of state? Yes No 3

4 41. Do the company s employees travel out of the country? Yes No 42. What percentage of annual work time do company employees use their own vehicles for work purposes? 43. Does the company check Motor Vehicle Records (MVRs) for new employees who may drive? Yes No Please explain: 44. Does the company currently enforce a drug and alcohol policy? Yes No Describe process: 45. Does the company have a post accident drug testing program? Yes No 46. Does the company sponsor an athletic team which employees participate? Yes No 47. Are physicals required by the company after o ers of employment are made? Please explain: Yes No 48. Does the company have any other insurance with this insurer? Yes No 49. Is the company involved with any labor interchange with any other businesses/subsidiaries? Yes No 50. Do any of the company s employees predominantly work at home? Yes No 51. Has the company had any tax liens or filed any bankruptcy within the last 5 years? Yes No 52. Are there any undisputed and unpaid Workers Compensation premiums due for you or Yes No any commonly managed or owned enterprises? 4

5 The information provided above is accurate to the best of my knowledge and belief, and Cluett may rely on this information when preparing its proposal and program pricing structure. We understand that this information is being supplied to Cluett for the purpose of preparing a proposal for Professional Employer Services. Authorized Client Signature Authorized Client Name (Please Print) Title Submitted for Proposal Authorization by: Cluett Representative Authorization to Prepare Proposal: Cluett Risk Manager Cluett Commercial Insurance Agency, Inc. (800)