Workers' Comp - Supplemental Information

 

Individual Completing Form
Name:

Agency:
Insured's Name
Name:
The Workforce
Number of employees
Full Time
(over 30 hrs/week)		 Part Time

Wages 
Starting Average

Maximum

Any change in payroll anticipated? (+/- what %)

# Union Employees # W-2's filed last year

Hiring Practices
Do you use written pre-employment applications? 
Are prior references checked?
Do you require pre-placement physicals?
Do you perform drug testing?
If YES, under which circumstances:
Employee Benefits
Do you provide health insurance?
Eligibility period: Number of employees enrolled:
% of premium paid by employer:
Who is your health insurer?
Describe any other employee benefits you provide:
Safety Program
Do you have a written safety program? 
Do you have a formal safety committee?
How often do they meet?
Are written accident investigations performed?
Any employee suggestion or incentive programs?
Do you have a formal employee orientation and training program?
Is there a disciplinary procedure for safety rule violation?
Do you provide light or modified work for injured employees?
Exposure Description
How many rooms do you have? 
Average occupancy (%) 
How long have you owned / managed this property? 
Describe any non-lodging / non-food service exposures
How many shuttles do you operate?
Radius of operation
Do you own other businesses?
If you have multiple locations and there are exceptions to above, please provide specific details:

  

 


9171 Towne Centre Drive, Suite 200
San Diego, CA 92122
(800) 420-4678   (858) 597-0830 Fax


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