Today's Date *

MM

DD

YYYY

Office Phone *

(###)

###

####

Mailing Address *

(including ZIP + 4 or Canadian Postal Code)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

LOCATIONS *

Tick the box to input your information.

Location 1

Location 2

Location 3

Desired Effective Date *

MM

DD

YYYY

Name *

First Name

Last Name

Office Phone *

(###)

###

####

Mobile Phone *

(###)

###

####

*

Tick the box to input your information.

Individual 1

Individual 2

Individual 3

Individual 4

Need more people to add?

*

Tick the box to input your information.

Entry 1

Entry 2

Entry 3

Entry 4

Entry 5

Need more to add?

Provide information for the past 5 years and use the remarks section for loss details. *

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Carrier 1

Carrier 2

Carrier 3

Carrier 4

Carrier 5

1. Does the applicant own, operate, or lease aircraft or watercraft? *

Yes

No

2. Do / have past, present, or discontinued operations involve storing, treating, discharging, applying, disposing, or transporting hazardous materials? (e.g., landfills, wastes, fuel tanks, etc.) *

Yes

No

3. Any work performed underground or above 15 feet? *

Yes

No

4. Any work performed on barges, vessels, docks, or bridges over water? *

Yes

No

5. Is the applicant engaged in any other type of business? *

Yes

No

6. Are sub-contractors used? *

(If "yes", give the percentage of work subcontracted.)

Yes

No

7. Any work sublet without certificates of insurance? *

(If "yes", payroll for this work must be included in the state rating entry above.)

Yes

No

8. Is a written safety program in operation? *

Yes

No

9. Is any group transportation provided? *

Yes

No

10. Are any employees under 16 or over 60 years of age? *

Yes

No

11. Are there any seasonal employees? *

Yes

No

12. Is there any volunteer or donated labor? *

(If "yes", please specify.)

Yes

No

13. Are there any employees with physical handicaps? *

(If "yes", please specify.)

Yes

No

14. Do employees travel out of state? *

(If "yes", indicate the state(s) of travel and frequency.)

Yes

No

15. Are athletic teams sponsored? *

Yes

No

16. Are physicals required after offers of employment are made? *

Yes

No