Workers Comp Supplemental Form

YOUR WHOLESALE INSURANCE SOLUTION

- Step 1 of 10

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Named Insured *

Number of years in business. *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Your customer's physical business address.

Insureds Website

Example: https://www.anywhere.com

EMPLOYERS CONTACT INFORMATION

Insurance Buyer *

First

Last

Insurance Buyer Email Address *

Insurance Buyer Phone Number *

Safety Contact *

First

Last

Safety Contact Email Address *

Safety Contact Phone Number *

Loss Report Recipient *

First

Last

Loss Report Receipient Email Address *

Loss Report Recipient Phone Number *

EMPLOYERS OPERATIONS

Please provide a complete and detailed description of the employer's operations below, or attach file.

Attach File

Complete and detailed description of the employer's operations

What is the employer's radius of operations in miles, from their place(s) of doing business? *

WORKFORCE INFORMATION

In the space below, or attach file, list each general job category, the number of employees in each, and the average hourly wage for each category:

General Job Category, Number of Employees, Average Hourly Wages

Attach File

General Job Category, Number of Employees, Average Hourly Wages

For each fixed or temporary location with 50 or more employees, fill in the requested information, or attach file.

Street Address or Location Name, City State, Zip Code, # of Occupied Buildings, Total # of Employees Working Here, Max # of Employees Onsite at Any Give Time

Attach File

For each fixed or temporary location with 50 or more

If the employer ever uses "day laborers" or hires at job site provide details. *

If any employees are paid on a piecework basis provide details. *

If part-time, temporary or leased and/or volunteer labor is used provide details. *

If subcontractors are used, explain what work is subbed out. *

Does the hiring process include substance testing? *

Does it offer post-offer pre-placement physicals? *

Is there employer contributed medical coverage? *

If yes, what % is enrolled? *

If a union hall dispatch system is used provide detail (flexibility, mininmums, etc.s *

EMPLOYER"S SAFETY PROGRAM

Is there a written safety program & rules? *

Is there a full time safety person? *

Does the employer have regular safety meetings with employees? *

Does the employer have a formal written Return to Work (RTW) policy and procedure? *

Attach File

If yes, please furnish a copy of the policy and procedure with this application.

Has the RTW policy & procedure been communicated to all current employees? *

If No, Is the employer willing to develop a formal program with the required elements? *

Written policy procedure? *

Policy and procedure communicated to employees? *

Makes every effort to provide meaningful transitional duty work whenever possible with each injured workers medical restrictions? *

Does top level management support the Return to Work effort? *

Will the employer use a Torus designated medical network provider if required? *

Does the risk utilize E-Verify to confirm that new hires are legally eligible to work in the US? *

LOSS HISTORY

For each workers compensation claim in the past 5 years that exceeded $50,000, describe the cause, injury type and any corrective action take by the employer. Upload file if preferred.

Attach File

For each workers compensation claim in the past 5 years that exceeded $50,000

EMPLOYER'S USE OF MOTOR VEHICLE AND/OR MOBILE EQUIPMENT

Cars and Light Trucks

Total Number of

Medium and Heavy Trucks

Total Number of

Tractor Trailer Rigs

Total Number of

Vans & Buses

Total Number of

In the space below, or attach a file, if employees do operate medium trucks, heavy trucks and/or tractor trailer rigs please describe how the vehicles are used in the business. Please also include how frequently they are used. If any are driven greater than 150 miles from where they are garaged, please explain. be it the cause, injury type and any corrective action take by the employer. Upload file if preferred.

Attach File (copy)

If employees do operate medium trucks, heavy trucks and/or tractor trailer rigs please describe how the vehicles are used in the business, etc.

Are MVRs obtained for all drivers before they are allowed to drive company vehicles? *

Are MVRs reviewed by management to ensure that they meet acceptability standards? *

Do employees use personal vehicles on the employer's business? *

Are there ever 4 or more employees in a vehicle together on company business? *

If yes, explain below how many vehicles are used for this, how many employees per vehicle, how often this occurs and the typical one-way distance that is driven with 4 or more in a vehicle. *

If the employer utilizes mobile equipment in their operations, provide details below, or attach a file, including the type of mobile equipment, the number of each type and any special qualifications for employees who operate the equipment. Examples of mobile equipment include forklifts and earth-moving equipment. *

Attach File

If the employer utilizes mobile equipment in their operations, provide details

SPECIAL EXPOSURES

If any current employees have exposure to asbestos, lead, mold or silica in their work, explain below: *

If the employer's prior work exposed employees to asbestos, lead, mold or silica in their work, explain below: *

If any employees have height exposure of 6 feet or greater, explain including the reason for the exposure, the maximum height above floor level and how many employees perform such work and what the safety controls are: *

If the business operations include "24-hour'' exposures, such as overnight travel, or work that is subject to the bunkhouse rule, please explain the nature, extent and duration of such work: *

If anyone who would be covered by workers compensation flies in a non-commercial aircraft for business purposes, provide details below including how often, who owns the aircraft and where they will travel. *

AGENCY/BROKERAGE INFORMATION

Agency/Brokerage Name *

Are you a MGA Preferred Agency Member? *

Agent/Broker Name *

First

Last

Email *

CERTIFY INFORMATION

Date *

Certify *

I understand that the information provided herein is essential and material to the agency/broker relationship and herby certify the above answers are truthful and accurate, to the best of my knowledge.

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