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Worker’s Comp – Pest Control
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
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
5650 - TERMITE CONTROL WORK — all operations —
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other employees
Enter your code manually
Number of Employees
Payroll $
*
# Shift Hours
*
1 - Add another classification?
*
Yes
No
Classification2
Employee Classification
Select one
CLICK HERE TO ENTER YOUR CODE MANUALLY
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
5650 - TERMITE CONTROL WORK — all operations —
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other 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
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
5650 - TERMITE CONTROL WORK — all operations —
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other 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
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
5650 - TERMITE CONTROL WORK — all operations —
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other 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
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
5650 - TERMITE CONTROL WORK — all operations —
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other 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
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
5650 - TERMITE CONTROL WORK — all operations —
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other 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
9031 - PEST CONTROL — all operations — including yard employees, Outside Salespersons and estimators
5650 - TERMITE CONTROL WORK — all operations —
9420 - MUNICIPAL, STATE OR OTHER PUBLIC AGENCY EMPLOYEES — all other 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)
Pest Control
Type of operations
Commercial
Agricultural
Residential
Industrial
Structural
Structural repairs or replacements
Dry Rot Wood Repair
Shower Pan Replacement
Chemical Treatment Services
Fumigation
Foam
Other
Provide Details
Percentage of tenting, in any?
*
Lawn treatment or care?
*
Yes
No
If yes, provide details
Other Service
Provide details
Mark all applicable services available
Ants
Spiders
Roaches
Fleas
Ticks
Wasps
Mosquitoes
Bees
Killer Bees
Bee Remova
Mice
Termites
Rats
Snakes
Racoons
Opossum
Skunks
Bats
Rodents
Gopher Control
Bird/Pigeon Control
Animal Trapping
Animal Removal
Bird/Rodent Proofing
Other
If other, provide details
Personal protective equipment required
*
Written Injury & Illness Prevention Program?
Yes
No
Written Haz-Com Program?
Yes
No
Written Heat Stress Program
Yes
No
Written Respiratory Protection Program?
Yes
No
Documented New Employee Orientation including Documented Training?
Yes
No
Written Fall Protection Program?
Yes
No
Special Written Procedures for working in Confined Spaces (Attics & Under Residences/Buildings?
Yes
No
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
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
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
Name
This field is for validation purposes and should be left unchanged.
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