Fillable USL&H AND STATE ACT WORKERS COMPENSATION (All Risks, Ltd)

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USL&H AND STATE ACT WORKERS COMPENSATION (All Risks, Ltd)

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USL&H Supplemental Application 011121 Page 1 of 4
RSGprograms.com
Marine
Department
Hunt Valley, MD Office
Richard
Lang
(P) 800-366-5810 x3094
(F) 410-828-8179
(E) rlang@ryansg.com
Tacoma, WA Office
Mary Ann Calkins
(P) 800-366-5810
x6056
(F) 253-267-6061
(E) mcalkins@ryansg.com
USL&H AND STATE ACT WORKERS’ COMPENSATION
PROGRAM SUMMARY
TYPE USL&H and State Act Workers’ Compensation
MINIMUM PREMIUM $10,000 Minimum premium (most class codes) WC & USL&H
combined
PROGRAMS AVAILABILITY Coverage is available in all states and will offer the combination
of State Act with USL&H Coverage (except monopolistic states,
where federal only coverage may be offered)
SECURITY Domestic, A+ (Superior) by A.M. Best rated carriers
SUBMISSION REQUIREMENTS ACORD Workers’ Compensation Application
Minimum 5 years and currently valued Loss Runs (not over 3
months old)
Latest Experience Modification Worksheet
Supplemental Application (attached)
In an effort to effectively quote this account as quickly as possible, it is vital you provide all of the information we have outlined
for you in the supplemental application. Thank you in advance for your assistance.
If yes, what association(s)?_____________________________________________________________________
USL&H Supplemental Application 011121 Page 2 of 4
RSGprograms.com
USL&H Supplemental Application
GENERAL INFORMATION
Name: ____________________________________________________________________________________________
(Complete name as it should appear on the policy including Inc., Corp., Ltd., etc.)
Physical Address: ______________________________________ _______________________ _____ _____________
Street City State Zip
Phone: ________________________ Fax: ________________________ FEIN: ________________________
Website: _______________________________________ Email Address: _________________________________
Policy Proposed Effective Date: __________________________ to __________________________
SECTION A: TOTAL PRIOR PAYROLL AND PREMIUM INFORMATION
Current Year
Prior Year (1)
Prior Year (2)
Prior Year (3)
Prior Year (4)
Premium
Payroll
SECTION B: EXPERIENCE
1. How many years have the Senior Officer, Partner or Proprietor operated this or a similar business? _______________
Please attach résumé if less than three years.
2. Does the applicant have evidence of continuous Workers’ Compensation coverage over the past
three years? Yes No
3. How many of the last five years, excluding current year, has the applicant done work subject to
the USL&H law? _________________
4. Does the applicant operate from a home or residential office? Yes No
5. Have payrolls fluctuated more than 50% between any two of the last five years? Yes No
6. Are you a member of any Professional Association(s)? Yes No
Marine Department
Hunt Valley, MD Office
Richard Lang
(P) 800-366-5810
x3094
(F)
410-828-8179
(
E) rlang@ryansg.com
Tacoma, WA Office
Mary Ann Calkins
(P) 800-366
-5810 x6056
(F) 253-267-6061
(E) mcalkins@ryansg.com
USL&H Supplemental Application 011121 Page 3 of 4
RSGprograms.com
SECTION C: ELIGILITY
1. How many states does the applicant operate in? _______________
2. What is the current Experience MOD? _______________ Copy attached? Yes No
3. Is the applicant in Chapter 11 Bankruptcy proceedings? Yes No
4. Has the applicant ever filed for voluntary or involuntary bankruptcy proceedings? Yes No
5. Has the applicant’s insurance been canceled or lapsed in the last two years due to non-payment
of premium? Yes No
SECTION D: RISK CHARACTERISTICS & ADDED EXPOSURES
1. Does the applicant use independent contractors in the conduct of its business? Yes No
If yes, for what purpose? _______________________________________________________________________
If yes, how are they paid? 1099’s Other (please explain): __________________________________
If yes, does the applicant obtain and retain Certificates of Workers’ Compensation insurance? Yes No
2. Does the applicant provide a group health plan for its employees? Yes No
3. Do employees work above 6 feet? Yes No
If yes, describe work and apparatuses used (ladders, scaffold, manlift): _________________________________
___________________________________________________________________________________________
4. Do employees work below grade more than 4 feet? Yes No
If yes, describe work and safety practices used: ____________________________________________________
___________________________________________________________________________________________
5. Do employees work in confined spaces? Yes No
If yes, describe work and advise who clears the space for safe entry: ___________________________________
___________________________________________________________________________________________
6. Does the applicant have an operating safety program? Yes No
If yes, does the safety program include Fall Protection? Yes No
Confined space entry practices? Yes No
7. Do part-time or seasonal employees make up more than 25% of the workforce? Yes No
8. Any exposure to employee leasing, alternative staffing, temporary, volunteer or donated labor? Yes No
If yes, provide detail:__________________________________________________________________________
USL&H Supplemental Application 011121 Page 4 of 4
RSGprograms.com
9. Do you own or operate any vessels, or do your employees do any work on or from any vessel
in navigation? Yes No
10. Is any otherwise uninsured work performed on or from barges or vessels as work platforms for
maritime maintenance/repair operations? Yes No
11. Does the risk include any welding work? Yes No
If yes, does the risk have welding fumes exposure from welding products, production
processes, and/or maintenance/repair operations? Yes No
SECTION E: OVER THE WATER EXPOSURES
**If any questions are answered yes, attach a copy of current MEL or P&I (including crew) coverage.
1. Will the applicant own, lease, charter or borrow any watercraft on a navigable waterway? Yes No
2. Will the applicant employ anyone as a Master or Member of the crew of any watercraft on
a navigable waterway? Yes No
3. Will the applicant employ anyone to perform any work on or from a watercraft under navigation? Yes No
4. Will the applicant contract any work to be performed on or from a watercraft under navigation
without reviewing proof of maritime coverages for the contractor’s workers? Yes No
NOTICE TO APPLICANTS: THIS APPLICATION MUST BE COMPLETED IN FULL AS THE QUOTE WILL BE BASED SOLELY ON
THE INFORMATION PROVIDED. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE CONTAINING FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. BY SIGNING THIS APPLICATION, THE SIGNOR WARRANTS THAT TO
HIS/HER BEST KNOWLEDGE, ALL INFORMATION GIVEN IS TRUE AND ACCURATE.
Signature: ____________________________________________________ Date: ___________________________
Name (print or type): ___________________________________________
RSG National Specialty Programs is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a subsidiary
of Ryan Specialty Group, LLC (RSG). RSG National Specialty Programs works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the public. Some
products may only be available in certain states, and some products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License # 0G97516).
©2021 Ryan Specialty Group, LLC
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USL&H AND STATE ACT WORKERS COMPENSATION (All Risks, Ltd)

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Completed 20 January 2021

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