R.R.I.S.  WORKERS' COMPENSATION SUPPLEMENTAL

Please provide the following contact information:

 (The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Cell Phone
Work Phone
Home Phone
FAX
E-mail
URL

           What are your estimated gross receipts for the next twelve months?

            What is your FEIN?

            What is your State Employer ID Number?

            How many years have you been in business?

            What is the legal entity of your business?

Individual Partnership Corporation LLC LLP Non-Profit Organization

            If you have a California Contractors License number, what is the number and what are the classes?

            Please give a desccription of your operations:

             Owner Name(s)                                              Date of Birth                       Social Security No

            Total Payroll

            Class Code                     Description                                 Number PT/FT  Emp                  Annual Payroll

            Does applicant own, operate or lease aircraft / watercraft?

            Have past, present or discontinued operations involved storing, treating, discharging, applying, disposing or transporting of hazardous     

              materials (e.g. landfills, wastes, fuel tanks, etc.)?

            Do you perform any underground work or work above 15 feet?

            Do you perform any work on barges, vessels, docks, bridges over water?

            Are you engaged in any other type of business? IF so, what type of business?

            Do you use subcontractors? If so, what percentage?

            Do you sub contract work without obtaining certificates of insurance from the subs?

            Do you have a written safety program in place?

            Do you provide group transportation?

            Do you have any employees under 16, over 60 or seasonal?

            Do you have volunteer or donated labor?

            Do you have employees with handicaps?

            Do your employees travel out of state?

            Do you sponsor athletic teams? If so, what type?

            Do you require physicals?

            Any prior insurance declined/cancelled or non-renewed?

            Do you provide employee health plans? If so, who is the carrier and what type of coverage?

            Do you have leased employees or labor interchange with another business or subsidiary?

            Do any employees work at home?

            Have you had any tax leins or bankruptcy in the past 5 years?

            How many full time employees / part time employees?

            Hours of operation:

            Any deliveries? If so, what is the radius?

            Is there any delivery? If so, what radius?