Fill - Free fillable TEMPORARY STAFFING AGENCY RENEWAL APPLICATION (Combined Commercial Package (Philadelphia Insurance Companies) PDF form

TEMPORARY STAFFING AGENCY RENEWAL APPLICATION

(Combined Commercial Package / Management & Professional Lines)

Name of Applicant:

Address:

City: State: Zip

Code:

Website: E-Mail:

Telephone

Number

SUBMISSION REQUIREMENTS

• ACORD Applications if requesting Property or Auto Coverage

• Completed signed/dated Staffing Agency Combined Supplemental Renewal Application

• Workers Comp class codes and estimated payroll breakdown

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.

SECTION I – GENERAL INFORMATION

1. Describe any changes in operation during the last year:

2. 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) % %

Temporary Staffing Agency

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3. How many of the Applicant’s Corporate Employees have been terminated or demoted in the

past twelve (12) months? Voluntary: Involuntary:

Laid Off:

Is any reduction in Corporate Employees anticipated within the next year? Yes No

5. 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.

6. 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

7. 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

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 conduct a prior employment check on all new hires? Yes No

11. Does the Applicant conduct criminal background checks? Yes No

Temporary Staffing Agency

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SECTION II - CRIME

Requested Limit Deductible

Insuring Agreement A1: Employee Theft and Client Coverage $ $

Insuring Agreement A2: ERISA Fidelity $ $

Insuring Agreement B: Forgery or Alteration $ $

Insuring Agreement C: Theft, Disappearance & Destruction – Inside the Premises $ $

Insuring Agreement D: Theft, Disappearance & Destruction – Outside the Premises $ $

Insuring Agreement E: Money Orders and Counterfeit Paper Currency $ $

Insuring Agreement F: Computer and Funds Transfer Fraud $ $

Additional Insuring Agreement: Third Party – “Off Premises” Coverage $ $

1. Are the Applicant’s financial statements prepared by an independent Certified Public

Accountant on an annual basis? Yes No

2. Are the owners involved in the daily operations of the company? Yes No

Are two signatures required on checks? Yes No

If yes, over what amount?

If no, who has the authority to sign checks:

4. Will any Contract/Temporary Placements have access to client money, securities, banking

systems, wire transfer systems or any sensitive computer data? Yes No

5. Will any Contract/Temporary Placements transport money, securities, or other valuable

property outside of their client’s premises? Yes No

If yes, please describe the type of property and value:

6. Will Contract/Temporary Placements be supervised and/or monitored by your clients when

performing services on their premises? Yes No

Temporary Staffing Agency

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FRAUD STATEMENT AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to 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).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN

APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.

APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN

INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE

IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO

KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE

OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM

INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY

AGENCIES.

APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER

FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A

FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).

APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE

PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER

OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION

OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR

PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR

COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT

MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.

APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS

FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF

MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING

INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,

FINES OR A DENIAL OF INSURANCE BENEFITS.

APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON

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 SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH

SUCH VIOLATION.

ME (PLEASE PRINT/TYPE) TITLE

(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE

DIRECTOR)

____________________________________________________

SIGNATURE DATE

SEC

TION TO BE COMPLETED BY THE

PRODUCER/BROKER/AGENT

PRODUCE

R AGENCY

(If this is a Florida Risk, Producer means Florida Licensed Agent)

PRODUCER LICENSE NUMBER

(If this a Florida Risk, Producer means Florida Licensed Agent)

ADDRESS (STREET, CITY, STATE, ZIP)

Temporary Staffing Agency

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CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL

QUESTIONNAIRE

Name of Applicant:

Address of Applicant:

City: State: Zip:

Website: www:

Nature of Operations:

1. Annual sales or revenue: $

2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)

belonging to customers, clients, or other third parties, other than employees?

If yes, please indicate the types of Personally Identifiable Information held (check all that apply):

Yes No

a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or

other State Identification Numbers

b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)

c. Credit or Debit Card Information

3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for

damage to their computer system(s) arising out of the operation of the Applicant’s computer

system(s)?

Yes No

b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a

lawsuit again

st the Applicant

alleging invasion or interference of rights of privacy or the

inappropriate disclosure of Personally Identifiable Information (PII)?

Yes No

c. During the last three (3) years, has the Applicant been the subject of an investigation or

action by any regulatory or administrative agency for privacy-related violations?

Yes No

d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a

claim being made against them for the coverage being applied for?

Yes No

PI-CYBE-APP (11/16)

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