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Instructions:Please answer all questions.If the questions does not apply to your business answer not applicable.(NA)
Address 1
ADDITIONAL GENERAL INFORMATION
Is the applicant a subsidiary of another entity or have any subsidiaries?
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Is the applicant engaged in any other type of business?
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Does the applicant get involved in any of the following operations?
Dam construction, including cofferdams and caisson building
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Levee or breakwater construction
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Subway or Tunnel construction
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Railroad construction
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Blasting
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Environmental/pollution work
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Asbestos abatement work
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Trucking-interstate or transporting or disposing of hazardous waste
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Chemical, petrochemical process, oil/gas well and nuclear work
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Occupational disease exposure
Y (YES)
N (NO)
N/A (NOT APPLICABLE)
Offshore drilling
Y
N
N/A
Underground or coal mining of any type
Y
N
N/A
Wrecking or demolition of structures, vessels, or buildings exceeding twostories in height
Y
N
N/A
Rocket or missile testing or launching
Y
N
N/A
Sawmills or logging
Y
N
N/A
Window cleaning in excess of two stories
Y
N
N/A
Bridge construction or painting
Y
N
N/A
Steel erection in excess of two stories
Y
N
N/A
Scaffolding-leasing, erection, or repair
Y
N
N/A
Sand or gravel digging
Y
N
N/A
Pesticide operations involving fumigation or tenting
Y
N
N/A
Crane operators
Y
N
N/A
Repossessing services
Y
N
N/A
If so, how high and is tie off equipment used?
Y
N
N/A
Please provide the following for each of the owners:
Employees Information
# of Employees per Category Example; (2 Clerical)
Weekly Payroll per Category Example:($750.00)
Please provide current and three years prior workers compensation carriers, if applicable
Email Three years loss runs report to kim@iretiworkerscomp.com.
Additional information may be requested after underwriting review.
Home
Benefits
Why you need it
Why a PEO
Benefits to the employer
Benefits to the employee
How much does it Cost?
How does it work?
About Us
Contact Us
SCHEDULE A CALL
