Fillable TEMPORARY STAFFING AGENCY NEW BUSINESS APPLICATION - MA (Philadelphia Insurance Companies)

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TEMPORARY STAFFING AGENCY NEW BUSINESS APPLICATION - MA (Philadelphia Insurance Companies)

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TEMPORARY STAFFING AGENCY NEW BUSINESS APPLICATION - MA
Name of Applicant:
Address:
City:
State:
Zip:
Website:
E-Mail:
Date Established:
Telephone Number:
Risk Management Contact:
Risk Management Email:
SUBMISSION REQUIREMENTS
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years
• ACORD Applications
• Completed signed/dated Temporary Staffing Agency Combined Supplemental Application
• Workers Comp class codes and estimated payroll breakdown
• New Ventures must provide a business plan inclusive of Applicant experience
Whenever used in this Application the term Applicant shall mean the Named Insured / Named Entity / Private
Company and its subsidiaries. Certain coverages addressed in this Application are provided on a Claims Made
and Reported basis, please read your policies carefully. Employee includes permanent and staffed / temporary
placed employees.
SECTION I – GENERAL INFORMATION
1.
Please provide a breakdown of the Applicant’s Corporate Employees, Temporary Placements, Recruiting,
PEO/ASO Operations:
Prior Year Actual
Next Fiscal Year
Projection
Total Number of Full Time Corporate Employees
(In House)
Total Number of Part Time Corporate Employees (In House)
Total Number of Independent Contractors
(In House)
Corporate Employee Payroll (In House)
Number of Contract/Temporary Placements
Total Payroll of all Contract/Temporary Placements (do not
include leasing payroll)
$
$
Number of Worksite Employees (PEO/ASO only)
Worksite Employees Payroll (PEO/ASO only)
$
$
Total Gross Receipts (deducting pass through payroll)
$
$
Direct Hire Percentage of Total Revenue
%
%
Total Percentage of Employees located in CA
(Contract/Temporary/PEO/ASO)
%
%
PI-TS-036-MA (06-17)
Temporary Staffing Agency
New Business Application
Page 1 of 4
© 2017 Philadelphia Consolidated Holding Corp.
08/2017
Clear Application
Print Application
2.
How many of the Applicant’s Corporate Employees have been terminated or demoted in the
past twelve (12) months? Voluntary: Involuntary: Laid Off:
3.
Is any reduction in corporate employees anticipated within the next year?
Yes
No
4.
Provide a breakdown of the types of staffing services offered to the Applicant’s clients
Administrative/ Clerical*
%
Daycare
%
Executive
%
Attorneys
%
Computer/IT Services
%
Construction/Carpentry/Skilled Labor
%
Financial/Accounting Professionals
%
Drivers/Transportation
%
Janitorial
%
Nanny Services
%
Light Industrial / Warehouse / Factory
%
Heavy Industrial
%
Security Services (Unarmed)
%
Security Services (Armed)
%
Architects/Engineers without Signoff Authority
%
Architects/Engineers with Signoff
Authority
%
Hospitality
%
Healthcare (excluding Doctors and
Dentists)
%
Teachers/Teacher Aides
%
Doctors/Dentists
%
*The following placements should be categorized as clerical, not IT or Financial/Accounting Professionals –
accounting clerks, bookkeepers, billing clerks, medical billers/coders, filing, receptionsists, data entry
services.
5.
Does the Applicant now, or will the Applicant place their employee(s) in a position which
requires the employee(s) to operate:
a. cranes, bulldozers, or trucks over 4,000 lbs.?
Yes
No
b. aircraft or watercraft?
Yes
No
6.
Does the Applicant transport temporary staffing employees to job sites?
Yes
No
If yes, please include a list of drivers along with respective dates of birth and answer the
following:
Does the Applicant perform MVR checks at time of hire for drivers?
Yes
No
Does the Applicant perform annual MVR checks thereafter?
Yes
No
7.
Does the Applicant specialize in clinical trial placements by recruiting participants or setting
up the trials?
Yes
No
8.
Does the Applicant have a hold harmless agreement in favor of the Applicant with its client
companies regarding liability for employment actions of the client company?
Yes
No
9.
Does the Applicant:
a.
have a standard employment application for all job applicants?
Yes
No
b.
have an employment handbook?
Yes
No
c.
document the receipt of the employee handbook by the employee?
Yes
No
d.
have an At Will provision in the employment application?
Yes
No
e.
have a written policy with respect to sexual harassment?
Yes
No
f.
have a written policy with respect to discrimination?
Yes
No
10.
Does the Applicant have a human resource department?
Yes
No
If no, describe how the function is handled:
11.
Does the Applicant conduct a prior employment check on all new hires?
Yes
No
12.
Does the Applicant conduct criminal background checks?
Yes
No
13.
Is the Applicant involved in any franchise operations?
Yes
No
PI-TS-036-MA (06-17)
Temporary Staffing Agency
New Business Application
Page 2 of 4
© 2017 Philadelphia Consolidated Holding Corp.
08/2017
Clear Application
Print Application
SECTION II – LIABILITY
1.
Employment Practices Liability (EPL)
a.
Quote requested?
Yes
No
b.
Limit Requested: $
c.
Deductible requested: $
SECTION III – POLICY INFORMATION
Coverage
Carrier
Limit
Deductible
Expiration
Date
Effective
Date
Premium
Employment
Practices Liability
$
$
$
SECTION IV – GENERAL SUMMARY
1.
With respect to the coverage addressed in this application, has any Underwriter refused,
canceled, or non-renewed coverage?
Yes
No
2.
With respect to the coverage addressed in this Application, has the Underwriter indicated
any intent to not offer renewal terms to the Applicant?
Yes
No
3.
Has the Applicant given written notice under the provisions of any prior policies providing
similar insurance of claims, or of specific facts or circumstances which might give rise to a
Claim being made against any person or entity applying for this insurance?
Yes
No
4.
No person applying for Employment Practice Liability (EPL) coverage is aware of any facts
or circumstances that may give rise to a Claim under these coverages. None,
or as noted below: (provide attachment if necessary)
PI-TS-036-MA (06-17)
Temporary Staffing Agency
New Business Application
Page 3 of 4
© 2017 Philadelphia Consolidated Holding Corp.
08/2017
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares t o the best of his/her
knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments
submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the
policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the
Company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION
FOR INSURANCE 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 SUBJECTS THAT
PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT
INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO
EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN
AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).
NAME (
PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
__________
__________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AG
ENCY
PRODUCER LICENSE NUMBER
PI-TS-036-MA (06-17)
Temporary Staffing Agency
New Business Application
Page 4 of 4
© 2017 Philadelphia Consolidated Holding Corp.
08/2017
Clear Application
Print Application
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TEMPORARY STAFFING AGENCY NEW BUSINESS APPLICATION - MA (Philadelphia Insurance Companies)

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Completed 29 July 2020

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