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Get your FREE Demo
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Workers’ Comp
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News
Contact
Worker’s Comp – Agriculture-Farming
Step 1 of 9
0%
Applicant Information
Company Name
*
EIN #:
*
Contact Name
*
Years of Operations
*
Applicant Email
Phone
Website
Location Full Address
*
Mailing Full Address
*
Description of Operation
*
Do you have Payroll?
*
Yes
No
If yes, Who's in charge of your payroll?
Company:
*
Contact Name:
*
Phone Number:
*
Email:
*
If no, will you have your payroll with us?
*
Yes
No
Business Ownership Type
Type of Business Ownership
*
Sole Proprietorship
Partnership/Corporation
Sole Propietorship
Name
*
Included?
Yes
No
Partnerships/ Corporations
If Corporation please specify type?
1120
1120s
1065
#1 Name
% Ownership 1
Included?
Yes
No
#2 Name
% Ownership 2
Included?
Yes
No
#3 Name
% Ownership 3
Included?
Yes
No
#4 Name
% Ownership 4
Included?
Yes
No
2016-2017 Employee Classification / Payroll estimates
Classification 1
1-Employee Classification
Select one
CLICK HERE TO ENTER YOUR CODE MANUALLY
0005 - NURSERIES — propagation and cultivation of nursery stock
0016 - ORCHARDS — citrus and deciduous fruits
0035 - FLORISTS — cultivating or gardening
0036 - DAIRY FARMS
0040 - VINEYARDS
0041 - POTATO CROPS
0044 - COTTON FARMS
0045 - ORCHARDS — nut crops
0050 - FARM MACHINERY OPERATION — by contractors — including yard employees
0096 - NUT HULLING, SHELLING OR PROCESSING
0171 - FIELD CROPS
0172 - TRUCK FARMS
0251 - IRRIGATION, DRAINAGE OR RECLAMATION WORKS OPERATION
2102 - FRUIT OR VEGETABLE EVAPORATION OR DEHYDRATING
2107 - FRUIT — fresh fruit packing and handling — including storage — N.O.C.
2108 - FRUIT — citrus fruit packing and handling — including storage
2117 - FRUIT OR VEGETABLE PROCESSING — frozen
2123 - FRUIT OR VEGETABLE PROCESSING — fresh – ready-to-eat
3507 - MACHINERY OR EQUIPMENT MFG. — agricultural, construction, mining or ore milling
4511 - ANALYTICAL OR TESTING LABORATORIES — including outside operations and sample collection — N.O.C.
6364 - IRRIGATION PIPE INSTALLATION — agricultural — all operations
6400 - FENCE CONSTRUCTION — metal or wood
7409 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — members of the flying crew
7410 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — not members of the flying crew
7539 - ELECTRIC LIGHT OR POWER COMPANIES — all operations — including construction or extension of lines
7706 - FIRE-FIGHTING OPERATION — not volunteers — all employees of Fire Department
7707 - FIRE-FIGHTING OPERATIONS — volunteers, serving with or without remuneration
8018 - STORES — wholesale — N.O.C.
8116 - FARM MACHINERY DEALERS — shop and outside — including demonstration and repair
8117 - STORES — feed, tack and farm supplies — retail
8209 - VEGETABLES — fresh vegetable and tomato packing and handling — including storage
8267 - MACHINERY AND EQUIPMENT DEALERS — secondhand — including incidental reconditioning or repairing
8286 - LIVESTOCK DEALERS OR AUCTION YARDS — not operating livestock feed yards, farms
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
0034(1) - POULTRY RAISING, EGG PRODUCTION AND HATCHERIES
0034(2) - SHEEP RAISING AND HOG FARMS
0038(1) - STOCK FARMS — beef cattle and horses
0038(2) - LIVESTOCK FEED YARDS — including the milling or blending of feed for use in operations
0079(1) - STRAWBERRY CROPS
2014(1) - GRAIN OR RICE MILLING
2111(1) - FRUIT OR VEGETABLE PRESERVING — including canning
2111(3) - FRUIT OR VEGETABLE PICKLING
2142(1) - WINERIES — all operations
3560(2) - MACHINERY MFG. — industrial — N.O.C.
3560(3) - MACHINERY MFG. — material handling equipment
3724(1) - MILLWRIGHT WORK — N.O.C. — erection or repair of machinery or equipment
4361(1) - PHOTOGRAPHERS — all employees — including receptionists — N.O.C.
6218(3) - LAND LEVELING — grading farm lands
6220(3) - LAND LEVELING — grading farm lands
7219(1) - TRUCKING FIRMS — N.O.C. — including terminal employees and mechanics
7424(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(3) - AIRCRAFT REMANUFACTURE, CONVERSION, MODIFICATION AND REPAIR COMPANIES
8720(1) - INSPECTION FOR INSURANCE, SAFETY OR VALUATION PURPOSES — N.O.C.
8831(1) - HOSPITALS — veterinary — all employees — including receptionists
8831(3) - KENNELS — boarding, grooming and care of domestic animals — all employees — including receptionists
9015(1) - BUILDING OPERATION — N.O.C. — all other employees — including resident or on-site managers
1 - Enter your code manually
1 - Number of Employees
1 - Payroll $
*
1 - # Shift Hours
*
1 - Add another classification?
Yes
No
Classification 2
2-Employee Classification
Select one
CLICK HERE TO ENTER YOUR CODE MANUALLY
0005 - NURSERIES — propagation and cultivation of nursery stock
0016 - ORCHARDS — citrus and deciduous fruits
0035 - FLORISTS — cultivating or gardening
0036 - DAIRY FARMS
0040 - VINEYARDS
0041 - POTATO CROPS
0044 - COTTON FARMS
0045 - ORCHARDS — nut crops
0050 - FARM MACHINERY OPERATION — by contractors — including yard employees
0096 - NUT HULLING, SHELLING OR PROCESSING
0171 - FIELD CROPS
0172 - TRUCK FARMS
0251 - IRRIGATION, DRAINAGE OR RECLAMATION WORKS OPERATION
2102 - FRUIT OR VEGETABLE EVAPORATION OR DEHYDRATING
2107 - FRUIT — fresh fruit packing and handling — including storage — N.O.C.
2108 - FRUIT — citrus fruit packing and handling — including storage
2117 - FRUIT OR VEGETABLE PROCESSING — frozen
2123 - FRUIT OR VEGETABLE PROCESSING — fresh – ready-to-eat
3507 - MACHINERY OR EQUIPMENT MFG. — agricultural, construction, mining or ore milling
4511 - ANALYTICAL OR TESTING LABORATORIES — including outside operations and sample collection — N.O.C.
6364 - IRRIGATION PIPE INSTALLATION — agricultural — all operations
6400 - FENCE CONSTRUCTION — metal or wood
7409 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — members of the flying crew
7410 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — not members of the flying crew
7539 - ELECTRIC LIGHT OR POWER COMPANIES — all operations — including construction or extension of lines
7706 - FIRE-FIGHTING OPERATION — not volunteers — all employees of Fire Department
7707 - FIRE-FIGHTING OPERATIONS — volunteers, serving with or without remuneration
8018 - STORES — wholesale — N.O.C.
8116 - FARM MACHINERY DEALERS — shop and outside — including demonstration and repair
8117 - STORES — feed, tack and farm supplies — retail
8209 - VEGETABLES — fresh vegetable and tomato packing and handling — including storage
8267 - MACHINERY AND EQUIPMENT DEALERS — secondhand — including incidental reconditioning or repairing
8286 - LIVESTOCK DEALERS OR AUCTION YARDS — not operating livestock feed yards, farms
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
0034(1) - POULTRY RAISING, EGG PRODUCTION AND HATCHERIES
0034(2) - SHEEP RAISING AND HOG FARMS
0038(1) - STOCK FARMS — beef cattle and horses
0038(2) - LIVESTOCK FEED YARDS — including the milling or blending of feed for use in operations
0079(1) - STRAWBERRY CROPS
2014(1) - GRAIN OR RICE MILLING
2111(1) - FRUIT OR VEGETABLE PRESERVING — including canning
2111(3) - FRUIT OR VEGETABLE PICKLING
2142(1) - WINERIES — all operations
3560(2) - MACHINERY MFG. — industrial — N.O.C.
3560(3) - MACHINERY MFG. — material handling equipment
3724(1) - MILLWRIGHT WORK — N.O.C. — erection or repair of machinery or equipment
4361(1) - PHOTOGRAPHERS — all employees — including receptionists — N.O.C.
6218(3) - LAND LEVELING — grading farm lands
6220(3) - LAND LEVELING — grading farm lands
7219(1) - TRUCKING FIRMS — N.O.C. — including terminal employees and mechanics
7424(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(3) - AIRCRAFT REMANUFACTURE, CONVERSION, MODIFICATION AND REPAIR COMPANIES
8720(1) - INSPECTION FOR INSURANCE, SAFETY OR VALUATION PURPOSES — N.O.C.
8831(1) - HOSPITALS — veterinary — all employees — including receptionists
8831(3) - KENNELS — boarding, grooming and care of domestic animals — all employees — including receptionists
9015(1) - BUILDING OPERATION — N.O.C. — all other employees — including resident or on-site managers
2 - Enter your code manually
2 - Number of Employees
2 - Payroll $
2 - # Shift Hours
2 - Add another classification?
Yes
No
Classification 3
3 - Employee Classification
Select one
CLICK HERE TO ENTER YOUR CODE MANUALLY
0005 - NURSERIES — propagation and cultivation of nursery stock
0016 - ORCHARDS — citrus and deciduous fruits
0035 - FLORISTS — cultivating or gardening
0036 - DAIRY FARMS
0040 - VINEYARDS
0041 - POTATO CROPS
0044 - COTTON FARMS
0045 - ORCHARDS — nut crops
0050 - FARM MACHINERY OPERATION — by contractors — including yard employees
0096 - NUT HULLING, SHELLING OR PROCESSING
0171 - FIELD CROPS
0172 - TRUCK FARMS
0251 - IRRIGATION, DRAINAGE OR RECLAMATION WORKS OPERATION
2102 - FRUIT OR VEGETABLE EVAPORATION OR DEHYDRATING
2107 - FRUIT — fresh fruit packing and handling — including storage — N.O.C.
2108 - FRUIT — citrus fruit packing and handling — including storage
2117 - FRUIT OR VEGETABLE PROCESSING — frozen
2123 - FRUIT OR VEGETABLE PROCESSING — fresh – ready-to-eat
3507 - MACHINERY OR EQUIPMENT MFG. — agricultural, construction, mining or ore milling
4511 - ANALYTICAL OR TESTING LABORATORIES — including outside operations and sample collection — N.O.C.
6364 - IRRIGATION PIPE INSTALLATION — agricultural — all operations
6400 - FENCE CONSTRUCTION — metal or wood
7409 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — members of the flying crew
7410 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — not members of the flying crew
7539 - ELECTRIC LIGHT OR POWER COMPANIES — all operations — including construction or extension of lines
7706 - FIRE-FIGHTING OPERATION — not volunteers — all employees of Fire Department
7707 - FIRE-FIGHTING OPERATIONS — volunteers, serving with or without remuneration
8018 - STORES — wholesale — N.O.C.
8116 - FARM MACHINERY DEALERS — shop and outside — including demonstration and repair
8117 - STORES — feed, tack and farm supplies — retail
8209 - VEGETABLES — fresh vegetable and tomato packing and handling — including storage
8267 - MACHINERY AND EQUIPMENT DEALERS — secondhand — including incidental reconditioning or repairing
8286 - LIVESTOCK DEALERS OR AUCTION YARDS — not operating livestock feed yards, farms
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
0034(1) - POULTRY RAISING, EGG PRODUCTION AND HATCHERIES
0034(2) - SHEEP RAISING AND HOG FARMS
0038(1) - STOCK FARMS — beef cattle and horses
0038(2) - LIVESTOCK FEED YARDS — including the milling or blending of feed for use in operations
0079(1) - STRAWBERRY CROPS
2014(1) - GRAIN OR RICE MILLING
2111(1) - FRUIT OR VEGETABLE PRESERVING — including canning
2111(3) - FRUIT OR VEGETABLE PICKLING
2142(1) - WINERIES — all operations
3560(2) - MACHINERY MFG. — industrial — N.O.C.
3560(3) - MACHINERY MFG. — material handling equipment
3724(1) - MILLWRIGHT WORK — N.O.C. — erection or repair of machinery or equipment
4361(1) - PHOTOGRAPHERS — all employees — including receptionists — N.O.C.
6218(3) - LAND LEVELING — grading farm lands
6220(3) - LAND LEVELING — grading farm lands
7219(1) - TRUCKING FIRMS — N.O.C. — including terminal employees and mechanics
7424(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(3) - AIRCRAFT REMANUFACTURE, CONVERSION, MODIFICATION AND REPAIR COMPANIES
8720(1) - INSPECTION FOR INSURANCE, SAFETY OR VALUATION PURPOSES — N.O.C.
8831(1) - HOSPITALS — veterinary — all employees — including receptionists
8831(3) - KENNELS — boarding, grooming and care of domestic animals — all employees — including receptionists
9015(1) - BUILDING OPERATION — N.O.C. — all other employees — including resident or on-site managers
3 - Enter your code manually
3 - Number of Employees
3 - Payroll $
3 - # Shift Hours
3 - Add another classification?
Yes
No
Classification 4
4 - Employee Classification
Select one
CLICK HERE TO ENTER YOUR CODE MANUALLY
0005 - NURSERIES — propagation and cultivation of nursery stock
0016 - ORCHARDS — citrus and deciduous fruits
0035 - FLORISTS — cultivating or gardening
0036 - DAIRY FARMS
0040 - VINEYARDS
0041 - POTATO CROPS
0044 - COTTON FARMS
0045 - ORCHARDS — nut crops
0050 - FARM MACHINERY OPERATION — by contractors — including yard employees
0096 - NUT HULLING, SHELLING OR PROCESSING
0171 - FIELD CROPS
0172 - TRUCK FARMS
0251 - IRRIGATION, DRAINAGE OR RECLAMATION WORKS OPERATION
2102 - FRUIT OR VEGETABLE EVAPORATION OR DEHYDRATING
2107 - FRUIT — fresh fruit packing and handling — including storage — N.O.C.
2108 - FRUIT — citrus fruit packing and handling — including storage
2117 - FRUIT OR VEGETABLE PROCESSING — frozen
2123 - FRUIT OR VEGETABLE PROCESSING — fresh – ready-to-eat
3507 - MACHINERY OR EQUIPMENT MFG. — agricultural, construction, mining or ore milling
4511 - ANALYTICAL OR TESTING LABORATORIES — including outside operations and sample collection — N.O.C.
6364 - IRRIGATION PIPE INSTALLATION — agricultural — all operations
6400 - FENCE CONSTRUCTION — metal or wood
7409 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — members of the flying crew
7410 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — not members of the flying crew
7539 - ELECTRIC LIGHT OR POWER COMPANIES — all operations — including construction or extension of lines
7706 - FIRE-FIGHTING OPERATION — not volunteers — all employees of Fire Department
7707 - FIRE-FIGHTING OPERATIONS — volunteers, serving with or without remuneration
8018 - STORES — wholesale — N.O.C.
8116 - FARM MACHINERY DEALERS — shop and outside — including demonstration and repair
8117 - STORES — feed, tack and farm supplies — retail
8209 - VEGETABLES — fresh vegetable and tomato packing and handling — including storage
8267 - MACHINERY AND EQUIPMENT DEALERS — secondhand — including incidental reconditioning or repairing
8286 - LIVESTOCK DEALERS OR AUCTION YARDS — not operating livestock feed yards, farms
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
0034(1) - POULTRY RAISING, EGG PRODUCTION AND HATCHERIES
0034(2) - SHEEP RAISING AND HOG FARMS
0038(1) - STOCK FARMS — beef cattle and horses
0038(2) - LIVESTOCK FEED YARDS — including the milling or blending of feed for use in operations
0079(1) - STRAWBERRY CROPS
2014(1) - GRAIN OR RICE MILLING
2111(1) - FRUIT OR VEGETABLE PRESERVING — including canning
2111(3) - FRUIT OR VEGETABLE PICKLING
2142(1) - WINERIES — all operations
3560(2) - MACHINERY MFG. — industrial — N.O.C.
3560(3) - MACHINERY MFG. — material handling equipment
3724(1) - MILLWRIGHT WORK — N.O.C. — erection or repair of machinery or equipment
4361(1) - PHOTOGRAPHERS — all employees — including receptionists — N.O.C.
6218(3) - LAND LEVELING — grading farm lands
6220(3) - LAND LEVELING — grading farm lands
7219(1) - TRUCKING FIRMS — N.O.C. — including terminal employees and mechanics
7424(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(3) - AIRCRAFT REMANUFACTURE, CONVERSION, MODIFICATION AND REPAIR COMPANIES
8720(1) - INSPECTION FOR INSURANCE, SAFETY OR VALUATION PURPOSES — N.O.C.
8831(1) - HOSPITALS — veterinary — all employees — including receptionists
8831(3) - KENNELS — boarding, grooming and care of domestic animals — all employees — including receptionists
9015(1) - BUILDING OPERATION — N.O.C. — all other employees — including resident or on-site managers
4 - Enter your code manually
4 - Number of Employees
4 - Payroll $
4 - # Shift Hours
4 - Add another classification?
Yes
No
Classification 5
5 - Employee Classification
Select one
CLICK HERE TO ENTER YOUR CODE MANUALLY
0005 - NURSERIES — propagation and cultivation of nursery stock
0016 - ORCHARDS — citrus and deciduous fruits
0035 - FLORISTS — cultivating or gardening
0036 - DAIRY FARMS
0040 - VINEYARDS
0041 - POTATO CROPS
0044 - COTTON FARMS
0045 - ORCHARDS — nut crops
0050 - FARM MACHINERY OPERATION — by contractors — including yard employees
0096 - NUT HULLING, SHELLING OR PROCESSING
0171 - FIELD CROPS
0172 - TRUCK FARMS
0251 - IRRIGATION, DRAINAGE OR RECLAMATION WORKS OPERATION
2102 - FRUIT OR VEGETABLE EVAPORATION OR DEHYDRATING
2107 - FRUIT — fresh fruit packing and handling — including storage — N.O.C.
2108 - FRUIT — citrus fruit packing and handling — including storage
2117 - FRUIT OR VEGETABLE PROCESSING — frozen
2123 - FRUIT OR VEGETABLE PROCESSING — fresh – ready-to-eat
3507 - MACHINERY OR EQUIPMENT MFG. — agricultural, construction, mining or ore milling
4511 - ANALYTICAL OR TESTING LABORATORIES — including outside operations and sample collection — N.O.C.
6364 - IRRIGATION PIPE INSTALLATION — agricultural — all operations
6400 - FENCE CONSTRUCTION — metal or wood
7409 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — members of the flying crew
7410 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — not members of the flying crew
7539 - ELECTRIC LIGHT OR POWER COMPANIES — all operations — including construction or extension of lines
7706 - FIRE-FIGHTING OPERATION — not volunteers — all employees of Fire Department
7707 - FIRE-FIGHTING OPERATIONS — volunteers, serving with or without remuneration
8018 - STORES — wholesale — N.O.C.
8116 - FARM MACHINERY DEALERS — shop and outside — including demonstration and repair
8117 - STORES — feed, tack and farm supplies — retail
8209 - VEGETABLES — fresh vegetable and tomato packing and handling — including storage
8267 - MACHINERY AND EQUIPMENT DEALERS — secondhand — including incidental reconditioning or repairing
8286 - LIVESTOCK DEALERS OR AUCTION YARDS — not operating livestock feed yards, farms
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
0034(1) - POULTRY RAISING, EGG PRODUCTION AND HATCHERIES
0034(2) - SHEEP RAISING AND HOG FARMS
0038(1) - STOCK FARMS — beef cattle and horses
0038(2) - LIVESTOCK FEED YARDS — including the milling or blending of feed for use in operations
0079(1) - STRAWBERRY CROPS
2014(1) - GRAIN OR RICE MILLING
2111(1) - FRUIT OR VEGETABLE PRESERVING — including canning
2111(3) - FRUIT OR VEGETABLE PICKLING
2142(1) - WINERIES — all operations
3560(2) - MACHINERY MFG. — industrial — N.O.C.
3560(3) - MACHINERY MFG. — material handling equipment
3724(1) - MILLWRIGHT WORK — N.O.C. — erection or repair of machinery or equipment
4361(1) - PHOTOGRAPHERS — all employees — including receptionists — N.O.C.
6218(3) - LAND LEVELING — grading farm lands
6220(3) - LAND LEVELING — grading farm lands
7219(1) - TRUCKING FIRMS — N.O.C. — including terminal employees and mechanics
7424(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(3) - AIRCRAFT REMANUFACTURE, CONVERSION, MODIFICATION AND REPAIR COMPANIES
8720(1) - INSPECTION FOR INSURANCE, SAFETY OR VALUATION PURPOSES — N.O.C.
8831(1) - HOSPITALS — veterinary — all employees — including receptionists
8831(3) - KENNELS — boarding, grooming and care of domestic animals — all employees — including receptionists
9015(1) - BUILDING OPERATION — N.O.C. — all other employees — including resident or on-site managers
5 - Enter your code manually
5 - Number of Employees
5 - Payroll $
5 - # Shift Hours
5 - Add another classification?
Yes
No
Classification 6
6 - Employee Classification
Select one
CLICK HERE TO ENTER YOUR CODE MANUALLY
0005 - NURSERIES — propagation and cultivation of nursery stock
0016 - ORCHARDS — citrus and deciduous fruits
0035 - FLORISTS — cultivating or gardening
0036 - DAIRY FARMS
0040 - VINEYARDS
0041 - POTATO CROPS
0044 - COTTON FARMS
0045 - ORCHARDS — nut crops
0050 - FARM MACHINERY OPERATION — by contractors — including yard employees
0096 - NUT HULLING, SHELLING OR PROCESSING
0171 - FIELD CROPS
0172 - TRUCK FARMS
0251 - IRRIGATION, DRAINAGE OR RECLAMATION WORKS OPERATION
2102 - FRUIT OR VEGETABLE EVAPORATION OR DEHYDRATING
2107 - FRUIT — fresh fruit packing and handling — including storage — N.O.C.
2108 - FRUIT — citrus fruit packing and handling — including storage
2117 - FRUIT OR VEGETABLE PROCESSING — frozen
2123 - FRUIT OR VEGETABLE PROCESSING — fresh – ready-to-eat
3507 - MACHINERY OR EQUIPMENT MFG. — agricultural, construction, mining or ore milling
4511 - ANALYTICAL OR TESTING LABORATORIES — including outside operations and sample collection — N.O.C.
6364 - IRRIGATION PIPE INSTALLATION — agricultural — all operations
6400 - FENCE CONSTRUCTION — metal or wood
7409 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — members of the flying crew
7410 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — not members of the flying crew
7539 - ELECTRIC LIGHT OR POWER COMPANIES — all operations — including construction or extension of lines
7706 - FIRE-FIGHTING OPERATION — not volunteers — all employees of Fire Department
7707 - FIRE-FIGHTING OPERATIONS — volunteers, serving with or without remuneration
8018 - STORES — wholesale — N.O.C.
8116 - FARM MACHINERY DEALERS — shop and outside — including demonstration and repair
8117 - STORES — feed, tack and farm supplies — retail
8209 - VEGETABLES — fresh vegetable and tomato packing and handling — including storage
8267 - MACHINERY AND EQUIPMENT DEALERS — secondhand — including incidental reconditioning or repairing
8286 - LIVESTOCK DEALERS OR AUCTION YARDS — not operating livestock feed yards, farms
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
0034(1) - POULTRY RAISING, EGG PRODUCTION AND HATCHERIES
0034(2) - SHEEP RAISING AND HOG FARMS
0038(1) - STOCK FARMS — beef cattle and horses
0038(2) - LIVESTOCK FEED YARDS — including the milling or blending of feed for use in operations
0079(1) - STRAWBERRY CROPS
2014(1) - GRAIN OR RICE MILLING
2111(1) - FRUIT OR VEGETABLE PRESERVING — including canning
2111(3) - FRUIT OR VEGETABLE PICKLING
2142(1) - WINERIES — all operations
3560(2) - MACHINERY MFG. — industrial — N.O.C.
3560(3) - MACHINERY MFG. — material handling equipment
3724(1) - MILLWRIGHT WORK — N.O.C. — erection or repair of machinery or equipment
4361(1) - PHOTOGRAPHERS — all employees — including receptionists — N.O.C.
6218(3) - LAND LEVELING — grading farm lands
6220(3) - LAND LEVELING — grading farm lands
7219(1) - TRUCKING FIRMS — N.O.C. — including terminal employees and mechanics
7424(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(3) - AIRCRAFT REMANUFACTURE, CONVERSION, MODIFICATION AND REPAIR COMPANIES
8720(1) - INSPECTION FOR INSURANCE, SAFETY OR VALUATION PURPOSES — N.O.C.
8831(1) - HOSPITALS — veterinary — all employees — including receptionists
8831(3) - KENNELS — boarding, grooming and care of domestic animals — all employees — including receptionists
9015(1) - BUILDING OPERATION — N.O.C. — all other employees — including resident or on-site managers
6 - Enter your code manually
6 - Number of Employees
6 - Payroll $
6 - # Shift Hours
6 - Add another classification?
Yes
No
Classification 7
7 - Employee Classification
Select one
CLICK HERE TO ENTER YOUR CODE MANUALLY
0005 - NURSERIES — propagation and cultivation of nursery stock
0016 - ORCHARDS — citrus and deciduous fruits
0035 - FLORISTS — cultivating or gardening
0036 - DAIRY FARMS
0040 - VINEYARDS
0041 - POTATO CROPS
0044 - COTTON FARMS
0045 - ORCHARDS — nut crops
0050 - FARM MACHINERY OPERATION — by contractors — including yard employees
0096 - NUT HULLING, SHELLING OR PROCESSING
0171 - FIELD CROPS
0172 - TRUCK FARMS
0251 - IRRIGATION, DRAINAGE OR RECLAMATION WORKS OPERATION
2102 - FRUIT OR VEGETABLE EVAPORATION OR DEHYDRATING
2107 - FRUIT — fresh fruit packing and handling — including storage — N.O.C.
2108 - FRUIT — citrus fruit packing and handling — including storage
2117 - FRUIT OR VEGETABLE PROCESSING — frozen
2123 - FRUIT OR VEGETABLE PROCESSING — fresh – ready-to-eat
3507 - MACHINERY OR EQUIPMENT MFG. — agricultural, construction, mining or ore milling
4511 - ANALYTICAL OR TESTING LABORATORIES — including outside operations and sample collection — N.O.C.
6364 - IRRIGATION PIPE INSTALLATION — agricultural — all operations
6400 - FENCE CONSTRUCTION — metal or wood
7409 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — members of the flying crew
7410 - AIRCRAFT OPERATION — agricultural — dusting, spraying and seeding — not members of the flying crew
7539 - ELECTRIC LIGHT OR POWER COMPANIES — all operations — including construction or extension of lines
7706 - FIRE-FIGHTING OPERATION — not volunteers — all employees of Fire Department
7707 - FIRE-FIGHTING OPERATIONS — volunteers, serving with or without remuneration
8018 - STORES — wholesale — N.O.C.
8116 - FARM MACHINERY DEALERS — shop and outside — including demonstration and repair
8117 - STORES — feed, tack and farm supplies — retail
8209 - VEGETABLES — fresh vegetable and tomato packing and handling — including storage
8267 - MACHINERY AND EQUIPMENT DEALERS — secondhand — including incidental reconditioning or repairing
8286 - LIVESTOCK DEALERS OR AUCTION YARDS — not operating livestock feed yards, farms
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
0034(1) - POULTRY RAISING, EGG PRODUCTION AND HATCHERIES
0034(2) - SHEEP RAISING AND HOG FARMS
0038(1) - STOCK FARMS — beef cattle and horses
0038(2) - LIVESTOCK FEED YARDS — including the milling or blending of feed for use in operations
0079(1) - STRAWBERRY CROPS
2014(1) - GRAIN OR RICE MILLING
2111(1) - FRUIT OR VEGETABLE PRESERVING — including canning
2111(3) - FRUIT OR VEGETABLE PICKLING
2142(1) - WINERIES — all operations
3560(2) - MACHINERY MFG. — industrial — N.O.C.
3560(3) - MACHINERY MFG. — material handling equipment
3724(1) - MILLWRIGHT WORK — N.O.C. — erection or repair of machinery or equipment
4361(1) - PHOTOGRAPHERS — all employees — including receptionists — N.O.C.
6218(3) - LAND LEVELING — grading farm lands
6220(3) - LAND LEVELING — grading farm lands
7219(1) - TRUCKING FIRMS — N.O.C. — including terminal employees and mechanics
7424(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(1) - AIRCRAFT OPERATION — other than agricultural, scheduled or supplemental air carriers
7428(3) - AIRCRAFT REMANUFACTURE, CONVERSION, MODIFICATION AND REPAIR COMPANIES
8720(1) - INSPECTION FOR INSURANCE, SAFETY OR VALUATION PURPOSES — N.O.C.
8831(1) - HOSPITALS — veterinary — all employees — including receptionists
8831(3) - KENNELS — boarding, grooming and care of domestic animals — all employees — including receptionists
9015(1) - BUILDING OPERATION — N.O.C. — all other employees — including resident or on-site managers
7 - Enter your code manually
7 - Number of Employees
7 - Payroll $
7 - # Shift Hours
Operations and Benefits
Does the applicant ever allow employees to work more than 3 consecutive 12 hour shifts?
*
Yes
No
Is there a driving/delivery exposure?
*
Yes
No
If yes, what is frequency
Daily
Weekly
Other
Specify
Radius of operation/travel
0-50 miles
50-100
100+
Is a PUC/DMV filing required?
PUC
DMV
N/A
Any group transportation of employees?
*
Yes
No
If yes, how provided
Car
Truck
Van
Bus
# of employees transported / vehicle
# vehicles used to transport
Frequency
Daily
Weekl
Monthly
Are vehicles company owned?
Yes
No
If yes, types of vehicles
If yes, are vehicles taken home?
Yes
No
If yes, types of vehicles
# Of vehicles?
# Of drivers?
Vehicle/fleet maintenance program?
Yes
No
If yes, who does the servicing?
Outside vendor
In-house mechanics
Other
Specify
Do employees use personal vehicles for company business?
Yes
No
Any out of state, international or overnight (whiten state) travel?
Yes
No
If yes, please provide details-Why/Purpose?
Who will travel?
Where?
Duration?
Frequency?
Do any employees work from home?
Yes
No
# of employees who LIVE out of state:
# of employees who WORK out of state:
# Full time employees
*
# Part-time employees
# Seasonal Employees
# Volunteers
# of employees per location
Each box is one location, you can add more locations as needed
# of W-2's issued-last year
*
# of W-2's issued previous year
*
Any day laborers or temporary/employee leasing?
*
Yes
No
If yes, please provide details
How are employees paid?
*
Hourly
Piece rate
Commission
Flat salary
Other
Specify
Paid sick leave?
*
Yes
No
Paid vacation?
Yes
No
% of union employees
% of non union
if union, Exp date of contract
Actual average hourly wage for employees in governing class (hour) $
Retirement/Pension plan?
*
Yes
No
Does employer contribute?
Yes
No
Group medical provided?
*
Yes
No
If yes, name of healthcare provider
% of employees enrolled
% paid by employer
Do you use a specific medical provider to treat injured employees?
*
Yes
No
Are you currently participating in a MPN (Medical Provider Network)?
*
Yes
No
If yes, please provide the name of current MPN
CPR training provided?
*
Yes
No
# of employees certified?
RTW Program?
*
Yes
No
Does it include salary continuation?
*
Yes
No
Has the ownership of the applicable entity changed within the past 5 years?
*
Yes
No
If yes, provide details:
Hiring Practices-Employee Selection-Claims
Written Application?
*
Yes
No
Pre-hire drug testing?
*
Yes
No
Reference Checks?
*
Yes
No
Post accident drug testing?
*
Yes
No
Pre/post employment Physical?
*
Yes
No
MVR Checks?
*
Yes
No
Orthopedic back testing?
*
Yes
No
Audio hearing tests?
*
Yes
No
Formal job descriptions on file?
*
Yes
No
Criminal Background Checks?
*
Yes
No
Are personnel files documented for pre-existing injuries?
*
Yes
No
Do you have a formal written accident report?
*
Yes
No
Average claim reporting time frame
Are there set procedures for reporting claims?
*
Yes
No
Any Interchange of labor?
Yes
No
If yes, please explain
Another business
Subsidiary
Between departments
Other
Specify Other
Is job specific training provided?
*
Yes
No
Employee Orientation program?
*
Yes
No
If yes, is the orientation
Verbal only?
Verbal and Documented?
Employee to Supervisor ratio
Better than 4-1
5-1
6-1
7-1
>7-1
Subcontractors used?
*
Yes
No
If yes, for what purpose?
If yes, are certificates of insurance obtained and kept on file?
*
Yes
No
Independent contractors used?
*
Yes
No
If yes, for what purpose?
If yes, how are they paid?
1099's
Other?
Please explain
Safety Program and Organization - Work premises and Environment
Are owners active in daily operations?
*
Yes
No
If yes, are they excluded from coverage?
*
Yes
No
Active injury & illness prevention program?
*
Yes
No
Has lost control services been performed in the last year?
*
Yes
No
Active safety incentive program?
*
Yes
No
If yes, does it encompass all employees?
*
Yes
No
What type of incentive?
Has Cal/OSHA visited or cited your business in the last year?
*
Yes
No
If yes, does it encompass all employees?
*
Yes
No
If yes, please provide explanation
Do employees receive safety training/ orientation?
*
Yes
No
If yes, is the training
*
Formal/ Documented
Informal
Are safety meetings conducted?
*
Yes
No
If yes, how often?
Daily
Weekly
Monthly
Quarterly
Do you have a safety director or risk manager?
*
Yes
No
If yes, is the position full time or an additional responsibility of another employee?
Name and title
MSDS (Materials Safety Data Sheets) available for all chemicals and products used?
*
Yes
No
N/A
Any material handling exposures?
*
Yes
No
If yes, please explain
Any lifting exposures?
*
Yes
No
If yes,
<25 Lbs.
25-40
40+
If 40+, manual lifting or with assistance? Please explain
Forklift training provide?
*
Yes
No
N/A
If yes, annual certification?
Yes
No
Is all machinery/equipment properly guarded?
*
Yes
No
N/A
Any use of baler equipment?
*
Yes
No
Condition of equipment?
*
New
Good
Average
Written Lock Out/ tag out / block out procedures in place?
*
Yes
No
N/A
Respiratory program in place?
*
Yes
No
N/A
Are all equipment operators trained / certified?
*
Yes
No
N/A
What is the maximum height at which you will work?
What is used?
*
Ladder
Scaffolding
Scissor lifts
N/A
If scaffolding used, does the Insured build their own?
Yes
No
Personal protection equipment provided?
*
Yes
No
N/A
If yes, strict enforcement of utilization?
Yes
No
Is the building /premises?
*
Owned
Leased
Condition of premises
Excellent
Very Good
Average
What types of PPE?
# of years at current location?
Age of building occupied? (Years)
Agriculture - Farming
Is harvesting mechanized or manual?
*
Do you use contracted labor?
*
Yes
No
If yes, % of use?
Is housing provided?
*
Yes
No
If yes, # of employees housed
Any seasonal workers used for operations?
*
Yes
No
If yes, provide detail of when season begins and ends, # of seasonal employees hired, and if same employees hired, and if same employees used each season.
Does all farm machinery have safety guards intact?
*
Yes
No
Are employees transported by any vehicles on or off the premises?
*
Yes
No
If yes, please explain:
Any use of pesticides or fertilizers?
*
Yes
No
If yes, applications by
Employees?
Outside Vendor?
Any crop dusting operations?
*
Yes
No
If yes, services provided by
Employees?
Outside vendor?
Do family members work in operation?
*
Yes
No
Any work off premises?
*
Yes
No
If yes, please explain:
Dairy Farms:
What is the size of dairy herd?
*
Number of Bulls over 3 years old?
*
Does risk deliver any of their own milk products?
*
Yes
No
Does risk grow their own feed?
*
Yes
No
Is milking barn
*
Flat?
Elevated?
Average number of milking per day?
*
Protective Barriers?
*
Yes
No
Do employees conduct or complete work on sump pumps?
*
Yes
No
Are employees allowed to enter stem pipes around lagoon?
*
Yes
No
Are proper safety procedures in place for working near stem pipes, lagoons or sump pumps?
*
Yes
No
Any confined spaces exposures?
*
Yes
No
If yes, please provide details
Send a copy of written procedures and details of confined spaces training.
Prior Payroll and Premium Information
2015-2016
Policy #
*
Premium $
*
Total Annual Payroll $
*
Contact Name:
*
Phone:
Website:
Inspections Contact Name
*
Phone Number
Premium Audit Contact Name
*
Phone Number
Claims Contact
Phone Number
1 - Add a Previous Year?
Yes
No
2014-2015
Policy #
Premium $
Total Annual Payroll $
Contact Name:
Phone:
Website:
Inspections Contact Name
Phone Number
Premium Audit Contact Name
Phone Number
Claims Contact
Phone Number
2 - Add a Previous Year?
Yes
No
2013-2014 - Period
Policy #
Premium $
Total Annual Payroll $
Contact Name:
Phone:
Website:
Inspections Contact Name
Phone Number
Premium Audit Contact Name
Phone Number
Claims Contact
Phone Number
3 - Add a Previous Year?
Yes
No
2012-2013 - Period
Policy #
Premium $
Total Annual Payroll $
Contact Name:
Phone:
Website:
Inspections Contact Name
Phone Number
Premium Audit Contact Name
Phone Number
Claims Contact
Phone Number
Is Associate Member filling out this form?
Yes
No
Associate Name
Associate Email
Phone
IMPORTANT Disclaimer
*
I've read, understand and accept the following statement.
I Understand that 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.
Name
First
Last
Signature of Applicant
*
Date
Email
This field is for validation purposes and should be left unchanged.
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