Emplo yment Age ncies (Temporary Clerical or Retail) Application Applicant s Name: Age ncy Name: Age nt: Mailing Address: Address: Location Address: Web site Address: E-mail: Phone: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., S tandard Time at the addres s of the Applicant ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE. Ap plicant is : Individual Corporation Partnership Joint Venture Limited Liability Company Other (Specify): Limits Of Liability & Dedu ctible Requ es ted: General Aggregate (other than Products /Completed Operations) $ Products & Completed Operations Aggregate $ Personal & Advertising Injury (any one person or organization) $ Each Occurrence $ Damage To Premises Rented To You (any one premise) $ Medical Expense (any one person) $ Other Coverage, Restrictions, and/or Endorsements: $ Deductible $ 1. Des cription of operations : Number of years in business: Years of experience in this field: GLS-APP-80s (6-11) Page 1 of 5
2. Does the applicant carry Workers Compens ation?... Yes No If yes, is coverage provided for temporary employees?... Yes No 3. Do an y of the temporary emplo yee s hold profes s ional licen s es or certificates?... Yes No If yes, describe: 4. Are reference and background checks required on all temporary emplo yees?... Yes No 5. Is an y as s ignment of tem porary emplo yees longer than s ix months?... Yes No 6. Does applicant leas e emp loyees to others?... Yes No 7. Advis e p ercentage of: Perm anent Placement... % Temporary Placement... % 8. Es timated annual (exclud ing owner): Payroll: Receipts : Subcontracted Cos t: 9. Provide payroll b reakdown between: Clerical/Retail: Non-Clerical/Retail: 10. Provide payroll b reakdown and percentage of operations for each of the following: Pa yroll % Pa yro ll % Accounting/Finance/Insurance Administrative Architects/Engineers Attorneys/Paralegals Banking Bartenders/Bouncers Biotech/Research/Science/Lab Technicians Building Construction/Skilled Trade Clerical/Office Client Care Customer Support Daycare /Nannies/Babysitting Drivers/Truckers/Chauffeurs Educational/Teachers Employe e Leasing Engineering Farm Labor Food Service/Restaurants Hospitality IT/Software Deve lopment/help Desk Janitorial Service s Machine Operators (skilled) Machine Operators (unskilled) Marketing Modeling/Talent/Booking Agencies Mortgage/Real Estate Brokers Permanent Place ment Retail Road Construction Security/Protective Services Skilled Trade Other Describe: 11. Ad dition al Ins ured Inform ation: Name Ad dres s Interes t 12. Do all written contracts in clude a hold h armles s claus e in you r favor?... Yes No If no, explain when not required: 13. During the pas t three years, has any compan y can celed, declined or refus ed s imilar ins urance to the applicant (Not applicable in Missouri)?... Yes No If yes, explain: GLS-APP-80s (6-11) Page 2 of 5
14. Does applicant have other bus ines s ventures fo r which coverage is not requ es ted?... Yes No If yes, please explain and advise where insured: 15. Account his tory for p rio r five years and projected current year: Year Payroll Su bcontracted Cos t Total Revenue Current 1s t Prior 2nd Prio r 3rd Prior 4th Prio r 5th Prio r 16. Schedule of Hazard s : Loc. No. Clas s ification Des cription Clas s. Code Expos ure Premium Bas es (s) Gross Sales (p) Payroll (a) Area (c) Total Cost (t) Other 17. Prem is es information : Expos ure Building Contents Busines s Interruption Other Am ount Requ es ted Mortgagee or loss pa yee: Coins. % ACV/Repl. Cos t Additional coverages, restrictions and endorsement information: Caus e of Los s Deductible Other carriers participating on risk: Special Conditions 1. % 2. % 18. Prio r Carrier Inform ation: Carrier Policy Number Coverage Total Prem iu m Year: Year: Year: Year: Year: GLS-APP-80s (6-11) Page 3 of 5
19. Los s His tory Five Year Period: Indicate all claim s o r lo s s es (regardles s of fault and wheth er or not ins ured) or occurrences that may give ris e to claim s for the p rio r five years. Check this box if no los s es las t five years. Date of Los s Des cription of Los s Am ount Paid Am ount Res erved Claim Status (Open or Clos ed) 20. Attachm ents lis ted below mus t be includ ed with yo ur s ubmis s ion: a. Deta ils of all losses in excess of ten thousand dollars ($10,000). b. Workers Compens ation schedule showing class codes. 21. Do you have the following? (If yes, attach cop y). a. Independent contractor agreement?... Yes No b. Client service agreement?... Yes No This application does not bind the applicant nor the Company to complete the ins urance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued. FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an subjects such person to criminal and civil penalties. Not applicable in Neb ras ka, Oregon and Vermont. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide fals e, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties ma y 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pa y- able from ins urance proceeds shall be reported to the Colorado Divis ion of Insurance within the Department of Regulatory Agencies. WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA AP PLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application conta ining any false, incomplete, or misleading information is guilty of a felony in the third degree. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for pa yment of a loss or benefit or knowingly presents fals e information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any ins urance company files an subjects such person to criminal and civil penalties. GLS-APP-80s (6-11) Page 4 of 5
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance be nefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or bene fit or who knowingly and willfully pres ents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any ins urance company files an subjects such person to criminal and civil penalties. NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for ins urance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide fals e, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. P enalties include imprisonment, fines, and denial of insurance benefits. NOTICE OF NEW YORK APPLICANTS (Other than automobile): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conce als for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. APPLICANT S NAME AND TITLE: APPLICANT S SIGNATURE: (Must be signed by an active owner, partner or executive officer.) DATE: PRODUCER S SIGNATURE: DATE: NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT: IMPORTANT NOTICE As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided. GLS-APP-80s (6-11) Page 5 of 5