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Worker’s Comp – Landscape
Step 1 of 9
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Applicant Information
Company Name
*
EIN #:
*
Contact Name
*
Years of Operations
*
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
Employee Classification
Select One
CLICK HERE TO ENTER YOUR CODE MANUALLY
42 - LANDSCAPE GARDENING — all operations — including maintenance of gardens
171 - FIELD CROPS
9007 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION FOR SENIORS — age restricted
9009 - BUILDING OPERATION — commercial properties — all other employees
9010 - MOBILE HOME PARK OPERATION — all other employees — including on-site managers,
9011 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION — N.O.C. — not Homeowners Associations
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other employees — including laborers
8875(1) - PUBLIC COLLEGES OR SCHOOLS — all employees — including cafeteria, Clerical Office Employees
Enter your code manually
Number of Employees
Payroll $
*
# Shift Hours
*
1 - Add another classification?
Yes
No
Classification 2
Employee Classification
Select One
CLICK HERE TO ENTER YOUR CODE MANUALLY
42 - LANDSCAPE GARDENING — all operations — including maintenance of gardens
171 - FIELD CROPS
9007 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION FOR SENIORS — age restricted
9009 - BUILDING OPERATION — commercial properties — all other employees
9010 - MOBILE HOME PARK OPERATION — all other employees — including on-site managers,
9011 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION — N.O.C. — not Homeowners Associations
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other employees — including laborers
8875(1) - PUBLIC COLLEGES OR SCHOOLS — all employees — including cafeteria, Clerical Office Employees
Enter your code manually
Number of Employees
Payroll $
# Shift Hours
2 - Add another classification?
Yes
No
Classification 3
Employee Classification
Select One
CLICK HERE TO ENTER YOUR CODE MANUALLY
42 - LANDSCAPE GARDENING — all operations — including maintenance of gardens
171 - FIELD CROPS
9007 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION FOR SENIORS — age restricted
9009 - BUILDING OPERATION — commercial properties — all other employees
9010 - MOBILE HOME PARK OPERATION — all other employees — including on-site managers,
9011 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION — N.O.C. — not Homeowners Associations
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other employees — including laborers
8875(1) - PUBLIC COLLEGES OR SCHOOLS — all employees — including cafeteria, Clerical Office Employees
Enter your code manually
Number of Employees
Payroll $
# Shift Hours
3 - Add another classification?
Yes
No
Classification 4
Employee Classification
Select One
CLICK HERE TO ENTER YOUR CODE MANUALLY
42 - LANDSCAPE GARDENING — all operations — including maintenance of gardens
171 - FIELD CROPS
9007 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION FOR SENIORS — age restricted
9009 - BUILDING OPERATION — commercial properties — all other employees
9010 - MOBILE HOME PARK OPERATION — all other employees — including on-site managers,
9011 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION — N.O.C. — not Homeowners Associations
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other employees — including laborers
8875(1) - PUBLIC COLLEGES OR SCHOOLS — all employees — including cafeteria, Clerical Office Employees
Enter your code manually
Number of Employees
Payroll $
# Shift Hours
4 - Add another classification?
Yes
No
Classification 5
Employee Classification
Select One
CLICK HERE TO ENTER YOUR CODE MANUALLY
42 - LANDSCAPE GARDENING — all operations — including maintenance of gardens
171 - FIELD CROPS
9007 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION FOR SENIORS — age restricted
9009 - BUILDING OPERATION — commercial properties — all other employees
9010 - MOBILE HOME PARK OPERATION — all other employees — including on-site managers,
9011 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION — N.O.C. — not Homeowners Associations
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other employees — including laborers
8875(1) - PUBLIC COLLEGES OR SCHOOLS — all employees — including cafeteria, Clerical Office Employees
Enter your code manually
Number of Employees
Payroll $
# Shift Hours
5 - Add another classification?
Yes
No
Classification 6
Employee Classification
Select One
CLICK HERE TO ENTER YOUR CODE MANUALLY
42 - LANDSCAPE GARDENING — all operations — including maintenance of gardens
171 - FIELD CROPS
9007 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION FOR SENIORS — age restricted
9009 - BUILDING OPERATION — commercial properties — all other employees
9010 - MOBILE HOME PARK OPERATION — all other employees — including on-site managers,
9011 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION — N.O.C. — not Homeowners Associations
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other employees — including laborers
8875(1) - PUBLIC COLLEGES OR SCHOOLS — all employees — including cafeteria, Clerical Office Employees
Enter your code manually
Number of Employees
Payroll $
# Shift Hours
6 - Add another classification?
Yes
No
Classification 7
Employee Classification
Select One
CLICK HERE TO ENTER YOUR CODE MANUALLY
42 - LANDSCAPE GARDENING — all operations — including maintenance of gardens
171 - FIELD CROPS
9007 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION FOR SENIORS — age restricted
9009 - BUILDING OPERATION — commercial properties — all other employees
9010 - MOBILE HOME PARK OPERATION — all other employees — including on-site managers,
9011 - APARTMENT OR CONDOMINIUM COMPLEX OPERATION — N.O.C. — not Homeowners Associations
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other employees — including laborers
8875(1) - PUBLIC COLLEGES OR SCHOOLS — all employees — including cafeteria, Clerical Office Employees
Enter your code manually
Number of Employees
Payroll $
# 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)
Landscaping
Any tree trimming performed that is of the ground?
*
Yes
No
Any boulder or tree removal performed?
Yes
No
Any use of tractors, loaders or similar equipment?
*
Yes
No
Any highway or median work conducted?
*
Yes
No
Any use chippers, mulchers, cherry pickers, booms or other similar equipment?
*
Yes
No
if yes, please explain
Any use of pesticides or fertilizers?
*
Yes
No
If yes, is the application completed by
Employee?
Outside vendor?
Any debris removal or land clearing activities?
*
Yes
No
If yes, please explain
Prior Payroll and Premium Information
2015 -2016
Policy #
Premium $
Total Annual Payroll $
Contact Name
Phone Number
Website
Inspections Contact Name
Phone Number
Premium Audit Contact Name
Phone Number
Claims Contact Name
Phone Number
1 - Add a Previous Year?
Yes
No
2014 -2015
Policy #
Premium $
Total Annual Payroll $
Contact Name
Phone Number
Website
Inspections Contact Name
Phone Number
Premium Audit Contact Name
Phone Number
Claims Contact Name
Phone Number
2 - Add a Previous Year?
Yes
No
2013 -2014
Policy #
Premium $
Total Annual Payroll $
Contact Name
Phone Number
Website
Inspections Contact Name
Phone Number
Premium Audit Contact Name
Phone Number
Claims Contact Name
Phone Number
Is Associate Member filling out this form?
*
Yes
No
Associate Name
Associate's 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.
Signature of Applicant
*
Date
Phone
This field is for validation purposes and should be left unchanged.
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