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Yes |
No |
Does applicant own, operate or lease aircraft/watercraft? |
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Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or ransporting of hazardous materials (landfills, wastes, fuel tanks, etc.) |
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Any work performed underground or above 15 ft.? |
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Any work on barges, vessels, docks, bridge over water |
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Is applicant engaged in any other type of business? |
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Are subs used? (If yes, specify % of work contracted in notes section.) |
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Any work sublet without certificates of insurance? |
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Is there a written safety program in operation? |
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Any group transportation provided? |
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Any employees under 16 or over 60 years of age? |
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Any seasonal employees? |
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Any volunteer or donated labor? |
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Has applicant been inspected by OSHA in the past 3 years? |
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Was applicant cited for any violations? |
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Any employees with physical handicaps? |
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Do employees travel out of state? |
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Are athletic teams sponsored? |
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Are physicals required after offers of employment are made? |
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Any other insurance with this insurer? (Cedar Hill / Zurich) |
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Any prior coverage declined/cancelled/non-renewed?(last 3 yrs) |
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Are employee health plans provided? |
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Is there labor interchange with any other business/subsidiary? |
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Do you lease employees to or from other employers? |
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Do any employees predominantly work at home? |
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Any tax liens or bankruptcy within last 5 years? |
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Any undisputed work comp premium due from you or any commonly managed or owned enterprises? (If yes, explain in notes section including entity name & policy numbers.) |
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Please provide an explanation for any ‘Yes' answers in the section below. |
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