WORKERS COMPENSATION SUPPLEMENTAL APPLICATION

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Aron Norton
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1 Named Insured: Prior Payroll and Premium Information Total Annual Payroll Premium $ Current Year: Prior Year: Prior Year: Prior Year: Prior Year: Operations and Benefits Hours of operation to Is there a driving/delivery exposure? q Yes q No If yes, what is frequency: q Daily q Weekly q Other: Radius of operations/travel: q <50 miles q q 100+ Is a PUC/DMV filing required? q PUC q DMV q N/A Are vehicles company owned? q Yes q No Number of employees transported per vehicle Paid sick leave? q Yes q No Paid vacation? q Yes q No Actual average hourly wage for employees in governing class $ /hour Has the ownership of the applicable entity changed within the past 5 years? q Yes q No If yes, please provide details: Hiring Practices Employee Selection - Claims Written application? q Yes q No Reference checks? q Yes q No Pre/post employment physicals? q Yes q No Orthopedic back testing? q Yes q No Formal job descriptions on file? q Yes q No Pre-hire drug testing? q Yes q No Post accident drug testing? q Yes q No MVR checks? q Yes q No Audio hearing tests? q Yes q No Criminal background checks? q Yes q No Are personnel files documented for pre-existing injuries? q Yes q No Do you have a formal written accident report? q Yes q No Are there set procedures for reporting claims? q Yes q No Is job specific training provided? q Yes q No Any interchange of labor? q Yes q No q Another business q Subsidiary q Between departments q Other: Independent contractors used? q Yes q No If yes, for what purpose? If yes, how are they paid? q 1099 s q Other Please explain: Page 1 of 8

2 Safety Program and Organization Work Premises and Environment Are owners active in daily operations? q Yes q No If yes, are they excluded from coverage? q Yes q No Active injury & illness prevention program? q Yes q No Has loss control services been performed in the last year? q Yes q No Active safety incentive program? q Yes q No If yes, does it encompass all employees? q Yes q No What type of incentive? Has Cal/OSHA visited or cited your business in the last year? q Yes q No If yes, please provide explanation on separate page. Are safety meetings conducted? q Yes q No Do employees receive safety training/orientation? q Yes q No If yes, how often? q Daily q Weekly q Monthly q Quarterly If yes, is the training q Formal / Documented q Informal q Other: Do you have a safety director or risk manager? q Yes q No Name and title: If yes, is the position full time or an additional responsibility of another employee? MSDS (Material Safety Data Sheets) available for all chemicals and products used? q Yes q No q NA Any material handling exposures? q Yes q No Any lifting exposures? q Yes q No Forklift training provided? q Yes q No q NA If yes, <25 lbs If yes, annual certification? q Yes q No If 40+, manual lifting or with assistance? Please explain Is all machinery/equipment properly guarded? q Yes q No q NA Any use of baler equipment? q Yes q No Condition of equipment? q New q Good q Average Are all equipment operators trained/certified? q Yes q No q NA Personal protection equipment provided? q Yes q No q NA Written lock out / tag out / block out procedures in place? q Yes q No q NA Respiratory program in place? q Yes q No q NA What is the maximum height at which you will work? If yes, strict enforcement of utilization? q Yes q No What types of PPE? What is used? q Ladder q Scaffolding q Scissor lifts q N/A If scaffolding used, does the insured build their own? q Yes q No Is the building / premises q Owned or q Leased? Condition of premises? q Excellent q Very good q Average # Of years at current location? Age of building occupied? year(s) Page 2 of 8

3 Contractors Contractors license number? Estimated annual gross sales? Years experience in trade? Estimated # of jobs per year? Percentage of work sub-contracted out? % What type? If subs used, does insured: q Check annually? q Directly supervise subs? Average # of certificates collected annually? Average # of waivers of subrogation needed? Indicate % of work conducted in each of the following operations (must equal 100% for each): New construction Remodeling Service/Repair Framing work Commercial Single custom homes Apts/Condos/ Tract Homes Interior Exterior If exterior work done, what is the maximum height exposure? Any use of cranes, booms or similar heavy construction equipment? q Yes q No Any work below grade? q Yes q No Max depth in feet % of total work Any confined spaces exposures? q Yes q No If yes, please provide details on separate page include copy of written procedures and details of Confined Spaces Training. Any work involving asbestos, hazardous product abatement, chemical/petroleum products, USL&H, underground tank or pipe replacement? q Yes q No Does this risk conduct work for the government or city municipality? q Yes q No Is the applicant involved in Wrap Up or OCIP projects? q Yes q No If yes, please provide percentage of total payroll dedicated to these projects, and advise detailed procedures on how applicant determines employee split between these projects and other contracts/projects (not Involving wrap up or OCIP ). Indicate % of work conducted in each of the following operations or mark not applicable q N/A Blasting Drilling Light pole work Demolition Tunneling Grading Wrecking Multi story buildings Gas mains Crane work Asbestos Highway work Scaffold set-up Roofing Concrete tilt-up Sewer exterior Framing Structural steel Bridge work Excavation Supervisory only Street/Road work Spray painting Dock/Sea walls Waterproofing Page 3 of 8

4 Janitorial Contractors Check appropriate exposures in the following areas: q Education q Facilitie q Nursing Homes q Apartment Houses q Hospitals q Airports q Office Buildings q Stores q Fire/Flood/Restoration q Government q Museums q Medical Offices q Hotels q Manufacturing Plants Indicate % of services provided (must equal 100%): General cleaning* Chimney cleaning Debris clearing Exterior window cleaning above 1st floor Industrial cleaning Ceiling tile cleaning Landscaping Heating, A/C ventilation service Carpet cleaning Elevator maintenance Parking lot cleaning Aircraft service and maintenance Snow removal Maid/housekeeping Fire/flood restoration Pressure or steam washing operations Pest control Floor waxing and Crime scene clean-up Servicing/cleaning of hoods/filters/ refinishing grease traps/etc * General Cleaning includes operations such as vacuuming, dusting, wastebasket trash pick up, floor & rug cleaning, restroom clean-up Do employees work in pairs or more? q Yes q No Employees supervised? q Yes q No Direct or roving supervision? q Direct q Roving Apartment Ops / Building Ops / Hotel/Motel Is housing provided? q Yes q No If yes, # of employees housed and describe their responsibilities: Are employees involved in property maintenance? q Yes q No If yes, provide details: Security Guards employed? q Yes q No If yes, provide details (i.e. armed or unarmed, hours on premises): Number of guest rooms? Room rates: q <$50 q $50-$100 q $100+ Rent rooms q Daily q Weekly q Monthly Any shuttle, limo or similar service? q Yes q No Any Restaurant exposures? q Yes q No Does it include 24 hour room service? q Yes q No Bar or lounge area? q Yes q No Any entertainment provided? q Yes q No Housekeeping exposures: Moving of furniture? q Yes q No Mattress flipping or rotating? q Yes q No If yes, how often and # of employees involved in process? Page 4 of 8

5 Automotive Services Any towing services provided? q Yes q No Any road repair assistance? q Yes q No Is there a mini-market on premises? q Yes q No If yes, any sales of alcoholic beverages? q Yes q No Open 24 hours? q Yes q No Is cashier s booth bullet proof? q Yes q No If yes, any contract towing? q Yes q No If yes, 24 hour exposure? q Yes q No Any fueling operations? q Yes q No Any security/surveillance cameras on premises? q Yes q No Any test driving of customers vehicles? q Yes q No Any transportation of customers? q Yes q No Access to freeway? q 0-1 mile q 1-2 miles q 2+ miles Any off-premises or mobile services? q Yes q No If yes, provide details including percentage of payroll dedicated: Do you have a ventilated/filtered spray booth for painting operations? q Yes q No q NA Do you have a written respiratory protection program? q Yes q No q NA Are employees properly trained in the use and care of respiratory protection equipment? q Yes q No q NA Has proper fit testing been provided to each employee and their assigned respirator? q Yes q No Are employees ASE trained and certified? q Yes q No If yes, how many employees? Landscaping Any tree trimming performed that is off the ground? q Yes q No Any use of tractors, loaders or similar equipment? q Yes q No Any boulder or tree removal performed? q Yes q No Any highway or median work conducted? q Yes q No Any use of chippers, mulchers, cherry pickers, booms or other similar equipment? q Yes q No Any use of pesticides or fertilizers? q Yes q No If yes, is the application completed by q Employee? q Outside Vendor? Any debris removal or land clearing activities? q Yes q No Manufacturing Machine Shops Any punch press or press brake machinery/equipment? q Yes q No Machine guarded: q Point of operation q Drive mechanism Age of machinery: q <2 yrs q 2-5 yrs q 5-10 yrs q 10+ yrs Accessible moving parts guarded on machinery/equipment? q Yes q No Types of machines (must equal 100%) Heavy Mid Light Any Computer Network Controlled (CNC) machinery? q Yes q No % of off-premise operations: If yes, where/what for? Is building properly ventilated? q Yes q No Is proper dust collection system in place q Yes q No Page 5 of 8

6 Restaurants Entertainment provided? q Yes q No Bar or separate lounge area? q Yes q No Fast food? q Yes q No Any catering? q Yes q No If yes, radius of operations: miles % of exposure Any delivery? q Yes q No Delivery hours to If yes, radius of operations: miles % of exposure Number of: Hosts Wait persons Bartenders Valet Busboys Cooks Average price of entrée? q <$5 q $5-$15 q $15+ Servicing, cleaning of hoods/filters/grease traps or related systems provided by: q Outside vendor q Employees Trucking Carrier Operations: q California only q Interstate Length of Haul. Total must = 100%: Under 50 Miles % % % % 501 1,000 % Over 1,000 % Filings: DOT# PUC# DMV/MCP# q Not applicable Please Check the Questions and Attached the Applicable Data: Motor carrier identification report, MCS-150: q Attached or q Not applicable Cargo classification: q See attached MCS-150 or q See below (check all that apply): q General Freigh q Liquids/Gases q Grain, Feed, Hay q Chemicals q Household Goods q Building Materials q Coal, Coke q Commodities q Mobile Homes q Passengers q Meat q Refrigerated Food q Motor Vehicles q Oil field Equipment q Garbage, Refuse, Trash q Beverages q Driveway/Tow away q Fresh Produce q Livestock q U.S. Mail q Paper Products q Logs, Poles Beams, q Metal Sheets q Intermodal Containers q Machinery, Lumber Coils, Rolls Dry Bullion Large Objects q Other Drivers: a) Number of drivers b) Number of owner / operators used c) Do the drivers load and unload their trucks? q Yes q No Please provide detail of the types of materials loaded / unloaded and any equipment used: Is the applicant enrolled in the DMV Pull Program? q Yes q No If so, how often? Is the applicant enrolled in the CHP BIT Program? q Yes q No Page 6 of 8

7 Retail / Wholesale Type of merchandise? Gross receipts: Wholesale % Retail % Warehousing? q Yes q No Any repacking or repackaging operations? q Yes q No operations: Assembly exposure? q Yes q No exposure: Any distribution exposure? q Yes q No If yes, by common carrier or does insured have a trucking exposure? Please explain on separate page. Agriculture - Farming Is harvesting mechanized or manual? Does all farm machinery have safety guards intact? q Yes q No Do you use contracted labor? q Yes q No If yes, % of use? Is housing provided? q Yes q No If yes, # of employees housed Any seasonal workers used for operations? q Yes q No employees hired, and if same employees used each season If yes, provide details of when season begins and ends, # of seasonal Are employees transported by any vehicles on or off the premises? q Yes q No on separate page. Any use of pesticides or fertilizers? q Yes q No If yes, services provided by q Employees? q Outside Vendor? Any crop dusting operations? q Yes q No If yes, services provided by q Employees? q Outside Vendor? Do any family members work in operation? q Yes q No Any work off premises? q Yes q No on separate page. Dairy Farms What is the size of dairy herd? Does risk grow their own feed? q Yes q No Number of bulls over 3 years old? Does risk deliver any of their own milk products? q Yes q No Is milking barn q Flat? q Elevated? Protective Barriers? q Yes q No Average number of milkings per day? Do any employees conduct or complete work on sump pumps? q Yes q No Are employees allowed to enter stem pipes around lagoon? q Yes q No Are proper safety procedures in place for working near stem pipes, lagoons or sump pumps? q Yes q No Any confined spaces exposures? q Yes q No procedures and details of Confined Spaces Training. If yes, please provide details on separate page include copy of written Page 7 of 8

8 Note: All information provided is subject to verification by way of an underwriting survey or inspection. We must be notified of any significant change in operations or payroll. Terms of insurance coverage may be cancelled for misrepresentation if information provided is inaccurate. WARNING: Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR or VT. In DC, LA, ME, TN, VA and WA insurance benefits may also be denied). In Florida, any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Colorado Disclosure: 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. I Have Read And Understood All Of The Questions Asked And Have Provided All Information Required. Signature of Applicant: Date: Page 8 of 8

MAVERICK SUPPLEMENTAL APPLICATION

MAVERICK SUPPLEMENTAL APPLICATION Insured: Eff Date: FEIN NO. Contact Name & Title: Tel. No.: Fax No.: INSURED HISTORY: Years in business: if less than 5 number of years in trade No. of locations Description