Marsh I McDonald s 2016 Workers Compensation Program Application Instructions

Transcription

1 Marsh I McDonald s 2016 Workers Compensation Program Application Instructions NOTICE: If you currently have your Workers Compensation insurance through AmTrust, AIG or Scottsdale, please call our office to discuss your application at General Information: Operator Payroll: Phone, Fax, , Type of Business. Legal Insured Name Fill in or make any changes where necessary. Fill in the name, title, duties and salary (or draw) for all licensed Owner/Operators and Executive Officers. Store Information: Store #: Legal Name, Address & Federal ID Number: Class Description: Indicate NATIONAL Store Number. A non-store location showing payroll (e.g. an office) has a number from 001 to 010. List all store entity names, addresses and Federal ID Numbers here. It is important that your policy include all legal entity names. This includes ALL office, warehouse and store locations which are to be covered by this policy. This would include a store manager, assistant manager, swing-manager or crew. This classification applies to an employee who does not physically work in the store. This applies mainly to clerical workers who work at a separate office location. Multi-Store Manager This classification would apply to an employee who oversees the operations of several stores. This employee does not work in the daily running of the store, in the cooking area or serving customers. Estimated Payroll: Indicate your estimated annual payroll for Additional Stores: Complete full information for any store you own that is not listed. Experience Mod: Indicate and attach a copy of your current Workers Compensation experience modification worksheet. Loss History: Attach currently valued Workers Compensation loss reports for 2011, 2012, 2013, 2014 and The loss reports must be valued within 90 days of submission date. Payroll Services: Answer the questions regarding current/future Payroll Processing Services. Please return this application via to mcdonalds@marsh.com or by fax to

2 Legal Named Insured: Owner/Operator Name: Primary FEIN: City: State: Zip: Business Phone: Cell Phone: Fax: Type of Business: Sole Proprietor Partnership LLC Subchapter S Corporation Corporation Number of Years as a McDonald s Owner/Operator: Section I. Owner/Operator & Corporate Officer Salary Name/Title Duties (Check One) Only Only Only Only Region: 2016 Estimated Annual Salary Include/Exclude Coverage for Workers Compensation* (Check One) *Should you choose to exclude coverage for Owner/Operators or officers, there will be no coverage for work related injuries under your Workers Compensation policy. If your choice of including or excluding coverage conflicts with state law, state law will apply. Most healthcare insurance policies exclude work related injuries. Rejection of coverage could leave you uninsured. Please refer to your health insurance policy to understand any exclusions that may exist. Section II. Store Estimated Payrolls (Attach additional sheets if needed.) NOTE: Do not include Owner/Operator or Corporate Officer Salary with store estimated payrolls. Only include Owner/Operator and Corporate Officer Salary in Section I. Marsh Sponsored Programs Workers Compensation Application Policy Term: 01/01/2016 to 01/01/2017

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4 Do you lease any employees from a leasing company or PEO (Professional Employment Organization)? Yes No If Yes, provide name of leasing company and a copy of leasing contract: Are any employees leased to other companies or businesses on a permanent or temporary basis? Yes No Is there any open air seating at heights (i.e., decks, roof tops or patios over water)? Yes No If Yes, indicate National Store Number(s): Do you have more than 50% Interest in any other business or operate multiple business enterprises? Yes No Do you offer delivery? Yes No Does your company own or operate any aircraft in the course of your business? Yes No Do you have any security guards? Yes No If Yes, provide a certificate evidencing coverage elsewhere. If Yes, indicate National Store Number(s): Current Experience Mod Effective *Attach a copy of Modification Worksheet or Policy Endorsement. Loss History Attach currently valued loss history for the years 2011, 2012, 2013, 2014 and Loss data must be valued within 90 days of submission. Authorized Contact Person: Please indicate by checking the boxes below if your stores are located in any of the following and provide the applicable National Store number(s) and highest number of employees at each location at any given time: Airport Amusement or Theme Park Exhibition or Convention Center Government or Municipal Building High Rise Building (50 or more stories) Hotel (25 or more stories or >250 rooms) Historic Location Medical Facility Military Base Stadium/Sports Complex Thru Way Store Transportation Terminal or Port (i.e. bus, rail, ferry or boat) University or Campus National Store Number(s) Highest Number of Employees at each Identify controls in place to mitigate exposure to robbery or other emergency situation. (Select all that apply): Hold up alarm system/panic button with central station monitoring Adequate exterior lighting At least three employees on premise at all times Surveillance cameras Closed Circuit TV or video data recording devices Robbery response training provided to employees Other None of the above

5 Which McDonald s Corporate Safety and Training programs are followed? (Select all that apply): Formal written safety program Safety meetings with Managers/Supervisors and Crew Routine safety inspections of restrooms, dining area, kitchen and restaurant exterior Accident investigations performed Transitional return to work offered for injured workers Use approved floor cleaning materials Use the slip resistant floor treatment in all stores Slip resistant shoe program in place funded Slip resistant shoe program in place unfunded New hire training including lifting and material handling; safe use, cleaning and maintenance of equipment; and proper use of kitchen equipment Annual review of MVRs for employees driving for business. Criminal back ground checks of employees performed None of the above Coverage/Limit Request The following coverage/limits will be requested unless the applicant advises differently: Coverage Part One: Workers Compensation Insurance Statutory Coverage based on Workers Compensation law Coverage Part Two: Employers Liability Insurance Bodily Injury by Accident: 100,000 Each Accident Bodily Injury by Disease: 500,000 Policy Limit Bodily Injury by Disease: 100,000 Each Employee Coverage Part Three: Other States Insurance All states except: ND, OH, WA, and WY Payroll Processing Services Please complete the following questions regarding Payroll Processing Services. 1. Do you currently work with a 3 rd party payroll processor or accountant to administer payroll for your business? Yes No 2. If yes, do these services come at a cost? Yes No 3. Would you be interested in bundling your Workers Compensation coverage with payroll processing for no additional charge? Yes No X McDonald s Owner/Operator Signature Date By signing this application, I agree that the statements made are true and correct. It is agreed that by providing an Authorized Contact Person on the Application, that individual is authorized to act on behalf of the McDonald s Owner/Operator regarding insurance. The Authorized Contact Person has full permission to discuss policy details that may otherwise be confidential. The McDonald s Owner/Operator may revoke this authorization at any time either by calling or writing Marsh.

6 In this transaction, Marsh Sponsored Programs, a service of Seabury & Smith, Inc. (Marsh), is acting as a producer for intermediaries, Andersen Group, Inc. and National CMServices, Inc., to gain access to AmTrust, AIG, and Scottsdale Insurance Company for this type of coverage, and not as your insurance broker. Alternative insurance products may be available in the insurance market place. Marsh is only offering this proposal. In accordance with industry custom we are compensated through commissions, calculated at 10% of the insurance premiums charged by insurers. We may also receive additional monetary and non monetary compensation from insurers, or from other insurance intermediaries, which may be contingent upon volume, profitability, or other factors. Our compensation may include payment from insurers for marketing or administrative related expenses or investments in technology. Our compensation may vary depending on the type of insurance purchased and the insurer selected. Where permitted by law, we may also earn and retain interest income on premiums held by Marsh on behalf of insurers during the period between receipt of such payments from clients and the time such payments are remitted to the applicable insurer. Marsh & McLennan Companies, Inc. and its subsidiaries which include Marsh Sponsored Programs, a service of Seabury & Smith, Inc. own equity interests in certain insurers and wholesale brokers. Information regarding such interests is available at

7 Sample Broker of Record Letter (to be completed on your company letterhead) Agent/Broker of Record Letter This is to certify that effective immediately Stonehenge Insurance Solutions, Inc., 300 Avenue of the Champions, Suite 222, Palm Beach Gardens, FL c/o Anderson Group, Inc., 534 Maple Valley Drive, Farmington, MO 63640, working in conjunction with Marsh Sponsored Programs, a service of Seabury & Smith, Inc. is my only authorized agent for the purpose of arranging workers compensation insurance on my behalf. I understand that AmTrust North America, through AmTrust insurance carriers, will release a quotation for my insurance to only one agent/broker, and that by signing this letter, I am terminating the ability of any other agent/broker (including my current agent/broker) to obtain a quote or represent me in relations to your company with respect to all quotation and renewal activity relating to the policy term effective January 1, The aforementioned organizations will assume Broker of Record responsibilities for the policy term effective January 1, The remainder of the current policy term, as well as the subsequent audit, will continue to be the responsibility of my current Broker of Record. This letter will remain valid until formally rescinded in writing by me. Owner/Operator Authorization Date Signed: Insured s Signature: Printed Name & Title: For purpose of account identification Policy Number: Named Insured: