WORKERS COMP QUALIFICATION FORM

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Bolds Insurance Brokerage

1447 Fourth Street

San Rafael, CA  94901

Phone: (415) 485-1700  Fax: (415) 485-1866

 

 

BUSINESS NAME/ADDRESS

Business Name

Street Address

City/State/Zip

          -     

 

CONTACT INFORMATION

Name

Phone Number

Fax Number

Email Address

 

ENTITY TYPE

Describe-other

 

DESCRIBE BUSINESS/OPERATIONS

 

Excavation Exposure yes no 
Asbestos Removal yes no 
Height Exposure  (outside) yes no 
Out of State Exposure yes no

 

GENERAL INFORMATION/SAFETY

Year Business Established
Fed Employer ID Number (FEIN)
Contractors Lic. # (if applicable)
Are owners active in management yes no
SB198 (OSHA) Program yes no
Safety meetings  
Safety training for NEW employees yes no
Vehicles owned yes no
Driving records checked yes no
Motor Carrier Permit # (if applicable)
Have you ever filed for Bankruptcy
Member of "Trade/Business Assoc." yes no  if yes, show below

 

EMPLOYMENT INFORMATION

Who is eligible for group medical
Name of provider
What % Medical Paid by Employer
Total number of employees
How many are full time
How many are part time
Number of W-2's filed last year (est.)
Average hourly wage
Total employee count is

 

Employment applications used yes no
Employees under 18 years old yes no
Modified work offered yes no
Written return to work program yes no
Incentive program yes no
Union employees yes no

 

PROJECTED PAYROLL (NEXT 12 MONTHS) 

Code Classification # of Emps Est Payroll*
$
$
$
$
$
Use comment section if additional payroll categories are needed

*do not include owner/partner/officer payroll

 

OWNER/PARTNER/OFFICER INFORMATION

Name Duties Title  Own% Incl./Excl.*
%
%
%
%
*coverage not normally available for sole-proprietors or partners

 

INSURANCE COMPANY    no prior insurance (skip below)

Current Year, loss runs available yes no  if no, complete below

Insurance Company Name

Policy Number

Expiration Date

 

1st Prior Year, loss runs available yes no  if no, complete below

Insurance Company Name

Policy Number

Expiration Date

 

2nd Prior Year, loss runs available yes no  if no, complete below

Insurance Company Name

Policy Number

Expiration Date

 

3rd Prior Year, loss runs available yes no  if no, complete below

Insurance Company Name

Policy Number

Expiration Date

 

ARE YOU INTERESTED IN OTHER COVERAGE(S)

General Liability yes no
Tool/Equipment Coverage yes no
Business Automobile yes no
Group Medical/Dental yes no

 

COMMENTS

 

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