Fillable APPLICATION FOR EXCESS WORKERS COMPENSATION POLICY (Risk Placement Services, Inc.)

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APPLICATION FOR EXCESS WORKERS COMPENSATION POLICY (Risk Placement Services, Inc.)

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Page 1 of 4
APPLICATION FOR EXCESS WORKERS COMPENSATION POLICY
1. Name of Applicant:
(As shown on Self-Insurance Permit)
2. Address:
Street City State Zip
3. Date qualifie
d as self-insured: Approval Dates:
4. Insured’s federal tax ID number:
5. Describe operations to be covered:
-Attach Copy
of Current annual report:
6. List any states to be covered by this insurance:
-Prov
ide Information for each State or Jurisdiction included in proposed coverage (Attach Separate page if necessary).
State WC Code No. Classification Estimated Gross Payroll Current Manual Rate Manual Premium
Total:
7.
Presen
t Program: Desired Program:
Carrier: Carrier:
Expiration: Expiration:
Specific Limits WC: Specific Limits WC:
EL: EL:
Retention : Retention:
Rate: Premium: Rate: Premium:
Other: Other:
Alternate Program: Quote needed by:
Page 2 of 4
8. Total Number of Employees: Full Time Part Time Seasonal
LIST ALL LOCATIONS ONLY COMPLETE COLUMS 2-10 FOR ANY LOCATION WHERE 100 OR MORE
EMPLOYEES WORK
ZIP CODE MUST
BE INCLUDED
FOR EACH
LOCATION
Location Address
(Street, City, State & Zip-
not mailing address)
1
# of
Emps
2
Hours of
Operation
3
Floors
Occupie
d (i.e.2
nd,
3
rd,
17
th
)
4
#
Emps
per
Floor
5
# Emps
on Shift
1
6
# Emps
on Shift
2
7
# Emps
on Shift
3
8
Building
Construction
9
# of
Stories
10
Year
Built
B) Is The Applicant’s property insurance underwritten through a HPR facility?
Yes No
9. Please provide10 years of aggregate loss experience and historical payroll by state:
State
Policy
Period
Total
Gross
Payroll
Indemnity Medical Expense Total
Aggregate
Losses
Incurred
Valuation
Date
Paid Reserved Paid Reserved Paid Reserved
10. Please provide 7 years of loss complete claims count data:
State Policy Period Total No. Claims Open Claims Closed Claims Closed Without
Payment
Valuation Date
Page 3 of 4
11. Provide 10 years of information on individual losses excess of $100,000: (Please use attached sheet if necessary)
State Date of
Loss
Description of Loss # of
Employees
Involved
Total
Paid
Total
Reserve
Total
Incurred
Valuation
Date
12. Are there any exposures outside the USA?
Yes No
If yes, describe:
13. Does Applicant manufacture, produce, refine, store, distribute or transport gasses, gasoline, or flammables? Yes No
If yes, describe:
14. Is the applicant engaged in the production, distribution, handling, or storing of explosives, or explosive
Yes No
substances?
If yes, describe:
15. Does applicant perform underground tunneling or sub aqueous operations? Yes No
If yes, describe:
16. Does the applicant perform any operations involving exposure to heights? Yes No
If yes, describe:
17. Has the applicant been cited for OSHA violations within the past five years? Yes No
If yes, describe:
18. Are there any exposures to toxic chemicals? Yes No
If yes, describe:
19. Have there been any significant changes in exposures over the last five years? Yes No
If yes, describe:
20. Does the applicant have any employees who may be subject to the Longshoreman and Harbor Workers Act, Yes No
Jones Act or Federal Employee’s Liability Act?
Unless endorsed the policy does not include federal acts coverage
If yes, describe:
21. Do the operations of the applicant include volunteer or donated labor? Yes No
If yes, explain:
22. Do any employees receive supplemental benefits in addition to workers’ compensation benefits? Yes No
If yes, describe:
23. Does applicant own, lease or charter any aircraft? Yes No
If yes, please complete an aircraft questionnaire:
24. Does applicant own, lease or charter watercraft?
Yes No
If yes, please complete a watercraft questionnaire:
Page 4 of 4
25. Supplemental Vehicular Information:
Number of :
Cars: Trucks: Tractors: Buses: Other:
.
States in which vehicles operate?
Does Applicant Use or provide buses, trucks, or vans to transport employees?
Yes No
If yes, list vehicles below including passenger capacity and radius of operation.
Does applicant transport goods for others?
Yes No
If yes, indicate type of goods transported, radius of operation and types of vehicles used.
26. Describe applicant’s own loss prevention program and medical facilities for treating injuries:
How often are engineering inspections performed?
27. Provide name of Claims Service Company (If insured is self administered please complete Self Administration Questionnaire):
Name of Service Company:
Address:
Street City State Zip
Contact Person:
28. If applicant utilizes Managed Care, complete Medical Loss Control Questionnaire.
WARNING: Any person who knowingly files an application for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime and also punishable by civil penalties in certain jurisdictions.
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APPLICATION FOR EXCESS WORKERS COMPENSATION POLICY (Risk Placement Services, Inc.)

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Completed 30 July 2020

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