KRM Risk Management Insurance Services, Inc.
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Insured’s FEIN: |
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Insured’s WCIRB#:: |
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Contractor’s Lic#: |
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Number of years in business years. If less than 5 years,
number of years in trade:
Is the owner active in the business: YES / NO
Duties performed
Describe operations of the insured
Year |
Payroll |
Premium |
Current |
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1st Prior |
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2nd Prior |
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3rd Prior |
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4th Prior |
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EXPOSURE INFORMATION-PREMISE-FIX LOCATION EMPLOYEE’S
Total number of employee’s:_
State
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Location |
Payroll |
Total # of Employees |
# of |
Maximum |
Type of Building |
Year Built |
# of |
Floors |
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If additional locations exist please included on a separate form.
Type of Building: (1.) Steel 3 stories or greater (2.) Frame 3 stories or less (3.) Concrete tilt up
OPERATIONS
Hours of operation to Number of days per week:
Out of state exposure: YES / NO if yes, name of states:
Percentage new construction: Residential % Commercial % Industrial %
Percentage of remodeling: Residential % Commercial % Industrial %
Percentage of repair work: Residential % Commercial % Industrial %
Percentage of work subcontracted: %
Any work performed above 2 stories: YES / NO if yes, explain
Any use of Cranes: YES / NO if yes, explain
Any use of Scaffolds: YES / NO if yes, explain
Are deliveries made: YES / NO Frequency: Daily Weekly Other:
Delivery radius: Under 50 miles 50-100 miles Over 100 miles
Vehicles owned: YES / NO If so, take home: YES / NO
Vehicle maintenance program: YES / NO
MVR “Pull” program: YES / NO
Any changes in operations in the last 5 years: YES / NO if yes, describe:
Condition of equipment: Excellent Good Poor
Any job site security provided: YES / NO if yes, describe:_
Does insured have a return to work program: YES / NO
If so, with full pay: YES / NO
Does insured have return to full time modified duty work plan: YES / NO
Is the insured willing to implement safety recommendations made by the carrier:
Is the insured willing to implement loss control recommendations made by the carrier
Additional Comments:
BENEFITS
What percentages of employees are covered by the plan: %
Waiting period: 30 days 60 days 90 days Other:
Name of group medical provider:
Who is eligible? All employees Only full time Other:
Does insured provide life insurance? YES / NO if yes, employer contribution %
Does insured provide Disability Insurance? YES / NO if yes, contribution %
Paid vacation: YES / NO Paid sick leave: YES / NO
401K Profit Sharing: YES / NO
HIRING PRACTICES
Complete written applications: YES / NO
References checked: YES / NO
Pre/Post employment physicals: YES / NO
Orthopedic back test: YES / NO
Drug/Substance abuse tests: YES / NO
MVR’s checked: YES / NO
Written Test YES / NO
Turnover rate %
How are potential new employees hired (check all that apply):
Referrals Word of mouth News Paper Ads
Recruiters Union Hall Other describe:
Employee turnover is: low average high
What is the hourly wage of the governing class of employees: $ per hour.
Piecework based compensation: YES / NO
Do employees utilize any safety protection: YES / NO describe:
Do employees travel out of state on business: YES / NO
if yes: # of employees
Number of employees are: Increasing: Stable: Decreasing:
Number of Employees telecommuting .
What percentage does employee work per week %
SAFETY
Person responsible for safety: phone #
Does insured use a specific medical provider to treat injured employees: YES / NO
Clinic Physician Emergency room Other:
Written safety program (SB198): YES / NO
Safety incentive program: YES / NO
Full time safety director: YES / NO
Part time (less 50%) YES / NO
Safety / Tailgate meetings conducted for all employees: YES / NO
How often:
Safety training program in place for employees: YES / NO
Equipment safeguards utilized: YES / NO if yes describe:
Equipment inspection / Maintenance program: YES / NO
if yes describe:
Slip and Fall Prevention Program in place: YES / NO
Hazardous Materials Communication program in place: YES / NO
Lock Out / Tag Out program in place: YES / NO
Industrial Truck / Vehicle program in place YES / NO
Violence intervention program: YES / NO
Drug / Alcohol awareness program: YES / NO
First aid kit kept at the job site: YES / NO
CASTASTROPHE EXPOSURE
Does insured work within 2 miles of the following building or facilities:
Government or Military base YES / NO
Financial Institutions including national/regional stock exchange YES / NO
Sport Stadiums/Arenas and Theme Parks YES / NO
Major Bridges, Tunnels or Dams YES / NO
Utilities or Power Generation Plants YES / NO
Transportation Hubs, Railroads, Airports or Shipping YES / NO
Historic/Symbolic buildings, monuments or parks YES / NO
TO BE COMPLETED FOR FARMS ONLY
Crops Grown |
Avg. Acreage |
Harvested Mechanically |
Type of Equipment |
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YES / NO |
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1: How many acres: 160 or less 161-499 500-999 1,000+
2: Housing Provided: YES / NO If so, how many employees ?
3: Transportation of employees: YES / NO
If yes how: Van Bus Airplane Other
Frequency: Daily Weekly Monthly Radius
4: Use Labor Contractor: YES / NO
5: Employees pay: Hourly rate Piece rate Combination Other
6: Operation outside of California: YES / NO
7: Dairy Barn: Elevated Carousel Flat Other
a) Number of Milking cows
b) Number of Bulls . Number of Bulls 3 years old & older:
c) Outside Veterinary Services: YES / NO
d) Artificial Insemination: YES / NO . Subcontracted: YES / NO
e) Hoof trimming: YES / NO . Subcontracted YES / NO
f) De-horn: YES / NO . Subcontracted YES / NO
8: Does insured harvest crops for others: YES / NO
If so, own equipment used: YES / NO
TO BE COMPLETED FOR TRUCKING EXPOSURES ONLY
1. Commodities Hauled – Breakdown by % of Revenue:
2. Any Hazardous or Oversized Cargo YES / NO
3. Type of Equipment – Type of Number of Vehicles:
Flatbed Tractor Trailer Double Trailer Tank
Refrigerated Other
4. Type of Carrier Truckload(TL) Less than Truckload (LTL)
5. Do drivers load and unload cargo? YES / NO
If yes, how often: % palletized loads? YES / NO
6. How are drivers compensated:
Per contract Hours logged Mileage Other
7. Radius of operations: Local % Medium % Long Haul %
Regular route: YES / NO
8. Out of state exposure: YES / NO If yes, which states
9. Are you in compliance with DOT? YES / NO
10. Any DOT/OSHA Citations in Last 4 Yrs? YES / NO
If yes, explain:
11. Any warehouse exposure? YES / NO If yes, explain
12. Any Driver Monitoring Devices? YES / NO
13. Are accidents reviewed for preventability YES / NO
14. Team Drivers YES / NO
15. Owner Operators YES / NO
16. Are Sub-Contractors hired? YES / NO
17. Are Lumpers/Helpers hired? YES / NO
18. Written maintenance program? YES / NO
19. In house mechanics? YES / NO
20. Vehicle maintenance records kept? YES / NO
21. Pre-trip inspections? YES / NO
22. Average age of Drivers:
23. Average age of vehicles:
BROKER INFORMATION
Does this broker currently control the workers’ compensation? YES / NO
If yes, # of years
Signature: _____________________________________________ Date: ___________________