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A. General Information
Your Name (required)
Your Email (required)
Your Phone (required)
Company Name (required)
Year Business Established (required)
Mailing Address (required)
Estimated annual sales
Insured Location (required)
Federal Employer ID Number: (required Please enter 999999999 if none)
B. COVERAGE INFORMATION
Worker's Compensation Insurance is being requested for which State(s):
Proposed Coverage Effective Date
Employer's Liability Limits (Choose One)
Standard Limits: $100,000 Each Accident, $500,000 Disease--Policy Limits, $100,000 Disease--Each EmployeeIncreased Limits (additional premium is charged) $500,000 Each Accident, $500,000 Disease--Policy Limit, $500,00 Disease--Each EmployeeCalifornia Statutory $1,000,000 Each Accident $1,000,000 Disease--Policy Limit, $1,000,000 Disease--Each Employee
Employees: Complete this section in its entirey. Be sure to account for ALL of your employees and their payroll. Or, provide a copy of your current declaration page and note any changes.
1. Solar Field Employees (including roof access)
2. Electrical Ground Workers
3. Clerical and Office Employees
4. Sales and Marketing Employees
Individuals Included/Excluded: Partners of Officers of your business can elect to be either included or excluded from Workers' Compensation benefits. If a partner or officer elects to be excluded from coverage, do not include his/her payroll in the section above. Whether electing to be included or excluded, all partner and officers must be listed below. Please include title and percentage of ownership in description box below:
Policy Term (From/To)
Please list prior losses:
Description of Loss
C. Other Information
Is applicant engaged in any other type of business?
Are Sub-Contractors used?
Any work sublet without certificates of insurance?
Is a formal safety program in operation?
Is there any volunteer or donated labor?
Do employees travel out of the country?
Any prior coverage declined/cancelled/non-renewed within the past 3 years? (not applicable in MO).
Do you lease employees to or from other employers?
Are all employees trained in how to act in the event of a robbery?
Are all employees provided with training/education on ergonomic issues?