Commercial Lines - Workers Compensation

What type of entity is this insurance going to be for?*

What is the name of the person/entity who will be the Policy Holder for this coverage (AKA The Named Insured)*

If you have not set up an official business, we can offer coverage for an individual.

Do you have a DBA?*

Yes
No

DBA means "Doing Business As" - it can be applicable to individuals who haven't set up a corporation or LLC but are operating under an assumed company name (i.e. John Smith DBA Fly Right Productions), OR it can be applicable to LLCs and corporations who have an official business name, but operate under other aliases (i.e. The Steinman Corp. DBA Greatfield Artisits).

Please list any and all DBAs you operate under*

Can you supply an FEIN?

Yes
No

An FEIN is a Federal Employer Identification Number issued to a company or individual by the IRS.

Please supply the FEIN.*

We need this in order to use automatic classification and entity acquisition with certain companies. This is also required for ALL workers compensation policies prior to binding coverage.

Please supply the Named Insured's Social Security Number*

Either a social security number or FEIN is required to bind any and all workers compensation coverage.

Address (No PO Boxes)*

Street Address City State ZIP Code

Contact Person*

First Last

Phone*

Email*

Enter Email Confirm Email

What year was this business established?*

Are you needing this coverage for a short term film production?

Yes
No

What date do you need this policy to start?*

What date do you need this policy to end?*

This should be the day AFTER all of your cast and crew have ceased work on the production.

What is the budget for your film production?*

How many cast and crew members will be working on your production?*

How much will you be paying your cast and crew members (do not include the pay for any managing members, directors, officers or owners in this figure)?*

If you are not paying your cast and crew, please estimate payroll based on what they would be paid if they were being paid (this is necessary to provide a quote). A minimum of $381/day for actors, and a minimum of $125/day for crew.

Please provide a synopsis of your production.*

Just a short summary of what your production is about and/or the types of scenes that will be shot.

Will the production include any stunts, jumps, falls, fight scenes, pyrotechnics, fireworks, aircraft, boats, water activities in pools, lakes, rivers, oceans or other bodies of water either natural or man-made, trains, railroads, military equipment, race tracks/courses, helicopters, hot air balloons, motorbikes, snowmobiles, ATVs, the use of blanks, squibs, guns (non-firing prop guns do not apply, unless they're being used as a blunt weapon) or weapons (such as knives, swords, clubs, etc.); or any other hazardous activities?*

Yes
No

If there is a claim due to hazardous activities, and you do not disclose them here, it is possible that the claim could be denied.

Please provide a description of the hazardous activities you'll be executing, the date you plan to execute them, and the safety precautions you're taking to ensure the cast and crew are not harmed during the execution of the activities.*

Please provide the name(s) of the managing members, directors, officers or owners of the company*

Will the managing members, directors, officers or owners of the company need to be included or excluded from the workers compensation coverage?*

Included
Excluded

Please note that including these individuals in the coverage will result in a higher premium.

Will the Named Insured need to be included or excluded from the workers compensation coverage?*

Included
Excluded

Please note that including the named insured in the coverage will result in a higher premium.

Please advise how much the owners, officers, directors or managing members that will need to be included in coverage will be paid for this production (Please see below for information needed):*

Please supply the name of each principal, and the amount they will be paid individually.

What is your anticipated operational budget for the year?*

This is how much you think it will cost you to do business in a year's time.

What is your anticipated annual revenue?*

This is how much money you anticipate your business will make in a year's time.

Please provide a detailed description of your business operations.*

If you are a Building Contractor/Construction Company, please provide us with your State Contractor's License Number:

Structure of Business Ownership **See BELOW for Information that is needed***

Please provide the following information for each person who owns part of the business: TITLE (CEO/Owner/President, Vice President, CFO/Treasurer, Secretary) PERCENTAGE OF OWNERSHIP, ANNUAL SALARY, SOCIAL SECURITY NUMBER, and whether to INCLUDE OR EXCLUDE them from the Worker's Compensation Coverage **(including owners in coverage will result in a more expensive policy)**

Has this named insured ever had Worker's Compensation coverage before?*

Yes
No

Please provide the policy number(s), premium(s) you paid and the start and end dates for your previous Worker's Compensation policy(ies):*

How many full-time employees do you have?*

How many part-time employees do you have?*

How many contractors (1099 workers) do you employ over the course of the year?*

Please describe the type of work your employees do and give an estimate of their annual salary. **See BELOW for example of information needed**

For example: Clerical/Bookkepping - 1, full-time, $60K/yr.; Janitorial - 1 part-time, $10K/yr. 3 full-time, $30K/yr. each; Sales - 2 part-time, $20K/yr. each, etc. The positions you will inform us about will vary depending on what type of business you own.

What type of work do your contractors perform and how much do you typically pay them for their work?***See BELOW for example of information needed**

For example: Accountant, $20/hour; Roofers, $45/hr.; Site Assistant, $18/hr. - The information you provide will vary depending on what you hire contractors to do.

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

Yes
No

If so, please explain:

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

Yes
No

If so, please explain:

Any work performed underground or above 15 feet?*

Yes
No

If so, please explain:

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

Yes
No

If so, please explain:

Is applicant engaged in any other type of business?*

Yes
No

If so, please explain:

Are subcontractors used?*

Yes
No

If so, please explain:

Any work sublet without certificates of insurance?*

Yes
No

If so, please explain:

Is a written safety program in operation?*

Yes
No

Please upload a copy of your safety program

Max. file size: 50 MB.

Any group transportation provided?*

Yes
No

If so, please explain:

Any employees under 16 or over 60 years of age?*

Yes
No

If so, please explain:

Any seasonal employees?*

Yes
No

If so, please explain:

Is there any volunteer or donated labor?*

Yes
No

If so, please explain:

Any employees with physical handicaps?*

Yes
No

If so, please explain:

Do employees travel out of state?*

Yes
No

If so, please explain:

Are athletic teams sponsored?*

Yes
No

Are physicals required after offers of employment are made?*

Yes
No

Do you have any other Worker's Compensation policies in force for this or any other business?*

Yes
No

If so, please explain:

Any prior coverage declined/cancelled/non-renewed in the last 3 years?*

Yes
No

If so, please explain:

Do you have any other Worker's Compensation policies in force for this or any other business?*

Yes
No

If so, please explain:

Are employee health plans provided?*

Yes
No

Do any employees perform work for other businesses or subsidiaries that your company owns?*

Yes
No

If so, please explain:

Do you lease workers to or from other employers?*

Yes
No

If so, please explain:

Do any employees predominantly work at home?*

Yes
No

If so, please explain:

Any tax liens or bankruptcy within the last 5 years?*

Yes
No

If so, please explain:

Any undisputed and unpaid workers compensation premium due from you or any company managed or owned enterprises?*

Yes
No

If so, please explain:

Do you obtain workers from a professional employer organization (PEO), employee leasing firm, labor contractor, or any third-party entity?*

Yes
No

If so, please explain:

Do you obtain temporary workers from other employers?*

Yes
No

If so, please explain:

Will you assign temporary laborers to your current or potential clients?*

Yes
No

If so, please explain:

Will you assign leased or long-term workers to your current or potential clients?*

Yes
No

If so, please explain:

Use any equipment that bends, forms, shapes, or cuts materials (e.g., power press)?*

Yes
No

If so, please explain:

Do you employ anyone who is related to you by blood or marriage?*

Yes
No

If so, please explain:

Employ any minors (under age 18)?*

Yes
No

If so, please explain:

Make any cash payments to employees or subcontractors?*

Yes
No

If so, please explain:

Provide meals or lodging in lieu of wages?*

Yes
No

If so, please explain:

Pay any employees by the piece?*

Yes
No

If so, please explain:

Do you perform any work at a maritime or offshore facility?*

Yes
No

If so, please explain:

Have any locations/operations for which coverage is not required?*

Yes
No

If so, please explain:

Have any operations outside of California?*

Yes
No

If so, please explain:

Perform any asbestos removal?*

Yes
No

If so, please explain:

Are you a member of any trade or business association?*

Yes
No

If so, please explain:

Do you offer an employee assistance program?*

Yes
No

Do you offer paid vacations?*

Yes
No

Do you offer paid sick leave?*

Yes
No

Do you have an injury and illness prevention program?*

Yes
No

Do you have a written return to work program for employees injured on the job?*

Yes
No

Do you document employee training?*

Yes
No

Do you document facility inspections?*

Yes
No

Have you received any OSHA citations within the past year?*

Yes
No

Do you provide temporary workers to other employers?*

Yes
No

Please check off the hiring practices implemented by your company:*

Job Descriptions
Pre-Placement Medical Screening
Drug-Free Workplace
Pre-Employment Reference Checks
Hiring of Union Employees

Have you ever had Worker's Compensation through the CA State Compensation Insurance Fund before (you must answer yes if you've ever had coverage with them - even if it was for a different company/entity)?*

Yes
No

If you answered "Yes" to the above question, please supply the policy number(s), named insured(s) and the start and end dates of any State Compensation Insurance Fund policies you've had before:

Is your current business all or part of an existing business that was purchased or acquired?*

Yes
No

If so, please see the description below for the additional information we'll need:

Name of the Previous Business: Name of the Previous Business Owner: Percentage of the business you acquired: Address of the Previous Business: Is your current payroll comprised of more than 50% new employees:

Please provide any additional information that you feel is relevant or any questions that you may have

Name

This field is for validation purposes and should be left unchanged.

(800) 696-3023

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Commercial - Workers Compensation