WORKERS’ COMPENSATION ADDITIONAL INFORMATION
WORKERS’ COMPENSATION ADDITIONAL INFORMATIONYour Agency:Goldblum Insurance Services, Inc.123 Atlantic, Suite 510Bakersfield, CA 93301Producer: Freddie KrogerCSR’s Name: Your NameCSR’s Phone: 555-555-5555CSR’s Fax: 555-555-5555SIC: 4651328The insured needs a workers’ compensation policy quote and wants a monthly reporting option.(Hint: This will be a direct bill item for the insurance company)The insured is not eligible for a dividend plan (participating plan).California’s statutory coverage limit for employer’s liability is set at 1,000,000 for the following categories, Each accidentDisease-policy limitDisease-each employeeThe insured performs work in CA and may perform work in all states except monopolistic.The following officers wish to be Included in the policy, Brandon A Stricker is the President (65 percent ownership). His main duty is Sales for the company andhis remuneration is 125,000.Brenton B Stricker is the Vice President (5 percent ownership). His main duty is Sales for the companyand his remuneration is also 125,000.Tammy C Beuller is the Secretary, Treasurer (30 percent ownership). Her main duty is Clerical for thecompany and her remuneration is also 125,000.Below is the X-Mod history summary for the insured, Upcoming renewal period: 1.142017: 1.102016: 0.762015: 0.77The supplemental application did not cover all the items the ACORD 130 required. After calling and emailing theinsured you have collected the following general information and confirmed, No involvement in any other type of business.No work sublet without certificates of insurance.They do have a written safety program in operation. The insured gave the following description,“Provides employees with a written safety manual.”No employees under 16 or over 60 years of age.No volunteer or donated labor.No employees with physical handicaps.No athletic teams are sponsored.No other insurance is placed with this insurer nor any other insurer.No prior coverage declined canceled or non-renewed in the past three years.No employees perform work for other businesses or subsidiaries.No employees are leased to or from other employers.No tax liens or bankruptcy within the last five years.No undisputed and unpaid workers’ compensation premiums are due
Workers’ Compensation InformationSTEP 1: Provide Your Estimated Annual Payroll Figures BelowClass CodeDescriptionEstimatedPayroll# Full Time # Part TimeEmployees Employees0105183Refrigeration 26 385,0005187Refrigeration 26 225,000805538Sheet Metal 27 575,0001005542Sheet Metal 27 215,000708742Sales 420,000308810Clerical 200,00040STEP 2: Complete the Attached Supplemental ApplicationSTEP 3: Provide 4 Years of Currently Valued Loss RunsSTEP 4: Return Completed Information Within 5 DaysPlease do not hesitate to contact us with any questions or concerns
Supplemental Applica onNamed Insured: Conditioned Air & Service, Inc.Contact Email Address: engineering@cas.comInsured’s FEIN: 87-8527416CONTACT NAMEPHONE NUMBERInspections:Brandon Stricker555-555-5556Premium Audit:Tammy Beuller555-555-5556Claims:Brenton Stricker555-555-5556PRIOR PAYROLL AND PREMIUM INFORMATIONTotal Annual PayrollPremium Current Year:2017 2,135,000 146,964Prior Year:2016 2,149,705 130,453Prior Year:2015 2,474,774 119,175Prior Year:Prior Year:OPERATIONS AND BENEFITSX YesBroker controlled account?NoAre you a member of the Chamber of Commerce?YesNoIf yes, provide county and membership #:Please provide a detailed description of the operation:Air conditioning contractor-commercialYears in business? 34Hours of operation: 7 to 4No. of shifts: 1 Does the applicant allow employees to work more than three consecutive 12-hour shifts?X YesIs there a driving or delivery exposure?X DailyIf yes, what is the frequency?Is a PUC/DMV filing required?X DMVPUCOther: 10 milesN/AIf yes, how provided?No100 X NoYesCarX 50-10011-50Any group transportation of employees?TruckVanBusNo. of employees transported per vehicle:If yes, types of vehicles: TrucksNo. of vehicles used to transport:If yes, are vehicles taken home:X NoYesNo. of vehicles:No. of drivers:Vehicle/fleet maintenance program?X YesFrequency:DailyWeeklyIs insured enrolled in DMV Pull program?NoAre driver acceptability standards in place?If yes, who does the servicing?Outside vendor:X NoYesRadius of operations/travel:WeeklyX YesAre vehicles company owned?NoMonthlyYesX NoX YesNoIf yes, provide details:XIn-house mechanics:Other:Does insured have and enforce the following policies for drivers:Alcohol/drug use:YesNoSeat belt use:YesNoDistracted driving:Any work-related injuries as a result of a prior motor vehicle accident within the past four years?YesYesNox NoIf yes, please provide details, including fault of accident and if subrogation was pursued on a separate page.Do employees use personal vehicles for company business?Do any employees work from home?X NoYesX NoYesNo. of employees who live/work out of state:Any out-of-state, international or overnight (within state) travel?YesXLiveWorkIf yes, provide details:Why/purpose?Who will travel?No. of employees: (verify number isWhere?consistent w/ number on ACORD application)No. of employees per location:No. of W-2s issued: Last Year:How are employees paid?Duration?Full: 45Part: 01. 452.Hourly:XSeasonal: 0Paid sick leave:Piece rate:YesVolunteers: 03.Previous Year:Any day laborers or temporary/employee leasing?Frequency?Commission:X No4.YesX NoFlat Salary:If yes, provide details on separate page.Use a separate page if needed.Paid vacation?Other:X YesNo
% of union employees:% of non-union:Actual avg. hourly wage for employees in governing class: Retirement/pension plan?X YesNoGroup medical provided?X YesNoDoes employer contribute?YesNoIf group medical is provided, who is the healthcare provider?% of employees enrolled: 100% of employees are enrolled% paid by employer:Do you have a wellness program (ie encourages and promotes employee health programs) in place?Do you use a specific medical provider to treat injured employees?X YesNoAre you currently participating in a MPN (Medical Provider Network)?X YesNoxYesNoIf yes, please provide the name of current MPN:CPR training provided?X NoYesX YesRTW program?No. of employees certified?NoDoes it include salary continuation?Has the ownership of the applicable entity changed within the past five years?YesNoX NoYesIf yes, please provide details:HIRING PRACTICES - EMPLOYEE SELECTION - CLAIMSWritten application?X YesReference checks?X YesNoPre-hire drug testing?NoPre/post employment physicals?Orthopedic back testing?X NoYesXFormal job descriptions on file?MVR checks?NoAre personnel files documented for pre-existing injuries?YesNoAverage claim reporting time frame:XEmployee to Supervisor ratio:Subcontractors used?YesNoYesX Yes6-1X YesNoX YesNo7-1If yes, are certificates of insurance obtained and kept on file?YesX NoYesIf yes, how are they paid?X NoYesAnother businessBetween departmentsSubsidiaryOtherX Verbal and Documented?Verbal Only? 7-1If yes, for what purpose? cranes, electrical, air balanceNoIndependent contractors used?NoAre there set procedures for reporting claims?If yes, is the orientation:X 5-1XYesDo you have a formal written accident report?If yes, please explain:NoBetter than 4-1NoNoAny interchange of labor?XIs job specific training provided?Employee Orientation Program?X YesAudio hearing tests?NoYesNoYesXPost-accident drug testing?XYesXYes1099s?NoIf yes, for what purpose?Other? Please explain.SAFETY PROGRAM AND ORGANIZATION - WORK PREMISES AND ENVIRONMENTAre owners active in daily operations?X YesNoIf yes, are they excluded from coverage?YesX NoActive injury & illness prevention program?X YesNoHas loss control services been performed in the last year?YesX NoYesX NoHas Cal/OSHA visited/cited your business in the last year?YesX NoYesNoX YesNoActive safety incentive program?If yes, does it encompass all employees?What type of incentive?Do employees receive safety training/orientation?If yes, is the training:X Formal / Documentedfull time orYesAny material handling exposures?Any lifting exposures? 25 lbsXMonthlyYesNoQuarterlyOtherNoName and title:an additional responsibility of another employee?MSDS (Material Safety Data Sheets) available for all chemicals and products used?If yes,Are safety meetings conducted?If yes, howDaily X Weeklyoften?InformalDo you have a safety director or risk manager?If yes, is the positionIf yes, please provide explanation on separate page.YesX NoX YesNox 25-4040 YesNoX N/AIf yes, please explain:Forklift training provided?YesNoX N/AIf yes, annual certification?YesNoAny use o f Baler equipment?YesX NoIf 40 , manual lifting or with assistance? Explain:Is all machinery/equipment properly guarded?YesNoX N/AWritten lockout/tagout/blockout procedures in place?YesNoXRespiratory program in place?YesX NoWhat is the maximum height at which you will work?What is used?X LadderScaffoldingNewCondition of equipment?N/AAge of equipment?x 0-5 yearsx Good5-10Are all equipment operators trained/ certified?N/AIf scaffolding used, does the insured build their own?Condition of premises?No. of years at current location?Excellent20 NoPlease see Contractors Section for further elaboration.YesNoPersonal Protection equipment provided?Very goodLeased?AverageIf yes, strict enforcement of utilization?YesNoNoN/AYesNo%X YesX OwnedIs the building/premises:10-20Please see Contractors Section for further elaboration.x Scissor liftsIf insured builds own scaffolding, provide % of annual operations involving scaffold setup and teardown compared to total operations.Written Fall Protection Program?Averagex YesxWhat types of PPE? Back Belts, Hard Hats, Long Pants, Safety shoesAge of building occupied? 38 years
This section must be completed by all applicants who are individuals, sole proprietorships, husband and wife,or partnerships (where the general partners are husband and wife).Please list below any relatives residing in your household who are employees of your business and to whom your books and records show payments to such relatives:Employed Relatives*NameRelationship to YouJob Title or DutiesEstimated Annual Remuneration 0 0 0 0 0Check here if there are no relatives residing in your household that are employed in your business.*Relatives are defined as: spouse, child by birth or adoption, stepchild, grandchild, son-in-law, daughter-in-law, parent, step-parent, parent-inlaw, grandparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, brother-in-law, sister-in-law, uncle, aunt, nephew, or niece.Note: Per California Labor Code, as an employer you are required to include in your Workers’ Compensation coverage all relatives residing inyour household who are your employees. Any policy issued based on information provided in this application will exclude coverage for residingrelatives if none are listed above.Note: All information provided is subject to verification by way of an underwriting survey or inspection. Wemust be notified of any significantchange in operations or payroll. Terms of insurance coverage may be cancelled for misrepresentation if information provided is inaccurate.Signature of Applicant:Date:CONTRACTORSContractors license number? CSLB#976431Years experience in trade? 31Estimated annual gross sales: 6000000Estimated number of jobs per year? 250Percentage of work sub-contracted out? 2%What type? cranes, electricalX Check annually?If subs used, does insured:Directly Supervise subs?Average no. of certificates collected annually?Average no. of Waivers of Subrogation needed?Indicate percentage of work conducted in each of the following operations (must equal 100% for each):1.)New Construction: 78%Remodeling: 22%Service/Repair: %2.)Commercial: 97 %Apts/Condos/Tract Homes: %Single Custom Homes: 3%3.)Interior: 70%Exterior 30%. If exterior work done, what is the max height exposure? 36 Feet 12’: 85 %Percentage of work/exposure:12’ to 24’: 10 %X LadderWhat is used?24’ to 40’: 5 % 40’: %x Scissor liftsScaffoldingN/AIf insured builds own scaffolding, provide % of annual operations involving scaffold setup and teardown compared to total operations. %Yesx Nox YesNoAny use of swing scaffolding?Any rooftop exposure?If yes, what percentage of total scaffolding use is swing? %If yes, what percentage of total work is on commercial flat roof? 10 %What percentage is on pitched rooftop? 0 %Any work performed on skylightsYesx NoFall Protection Program in place?X YesNox GuardrailsIf yes, please provide details:If yes, please select type below:x Safety Belt of Full Body HarnessSafety Netx Ladder Tie Offsx Training in Ladder/Scaffold PlacementOther, please describe:X YesAny use of cranes, booms or similar heavy construction equipment?Any work below grade?XYesAny confined spaces exposures?NoNoMax. depth in feet:% of total work:X NoYesIf yes, you must complete the Welding Exposure Supplemental App and include it with your submission.Any work involving asbestos, hazardous product abatement, chemical/petroleum products, USL&H, underground tank or pipe replacement?x NoYesDoes any welding exposure exist?If yes, please explain.YesNoIf yes, you must complete the Welding Exposure Supplemental App and include it with your submission.Does this risk conduct work for the government or city municipality?X NoYesIs the applicant involved in “Wrap Up” or “OCIP” projects?X YesNoIf yes, please provide percentage of total payroll dedicated to these projects, and advise detailed procedures on how applicant determines employee split between theseprojects and other contracts/projects (not Involving “wrap up” or “OCIP”).Indicate percentage of work conducted in each of the following operations or mark not applicableX N/ABlasting %Drilling %Light Pole Work %Multi-story buildings %Roofing %Bridge Work 0%Gas Mains %Excavation %Supervisory Only %Demolition %Crane Work %Concrete Tilt-up T %Tunneling %Asbestos %Sewer %Street/road Work %Grading %Highway Work %Ext. Framing %Spray Painting %Wrecking %Scaffold Setup %Structural Steel %Dock/sea walls 0%
California City Insurance CompanyLoss Analysis ReportInception Date 07-01-2015Expiration Date 07-01-2016A.R.D ---1234567-2015Conditioned Air & Service, Inc.1234 South Bird Dr., Anaheim, CA 92807District OfficeCancellation CodeQuote IDQuote TypeSC - LOS ANGELESE - Insured elsewhere100111111B - BASICAd hoc report produced on 03-20-2017BrokerageName Mountain Ridge Brokerage, Inc.Address 1111 Plainsfield, San Francisco, CA 94111Phone Number (555) 555-5555TotalsBoth Open and Closed Claims, Both Disability and Non-disability Claims for year bilityLitigated1001Paid CompensationPaid MedicalTotal Paid 56,576 32,528 89,104Estimated CompensationEstimated MedicalTotal Estimated/Incurred 68,173 62,116 130,289Policy Year 2015Estimated Annual 119,176Current Experience Mod 77.0%Governing Class 5538 ( 1 )ClaimsDiv# Claim ID---Claimant andPayroll Class06013806 BarrySPGreg5183StatusInjury Date Paid Comp PaidEst. Comp Est.Accident DescriptionMedicalMedicalopen07-21-2015 56,576 32,528 68,173 62,116 slippping off a ladder rung, w;dislocation; shoulder(s); fall/slipdisabilityladder/scaffoldrepresent non-litigcaseHINT: Total Reserve Total Incurred - Total Paid
InsuredPolicy NumberPolicy PeriodAgentWorkers' Compensation Loss Analysis ReportKnights of Rohan Insurance CompanyClaim Number: 1234567897Valued as of:03/13/20174:58:34 pmClaimant Name: Sam LapinskiClaim Status:AgeClass CodeDate of InjuryDate Reported to CarrierClose DateIn LitigationNature of InjuryBody PartCause24Location 001 Conditioned Air & Service, Inc.1234 South Bird Dr.,5183Anaheim, CA yNoLoss Adj. ExpenseSpc: StrainRehabTrunk: Low Back (Lmbr/Lmbo-Sac)SubrogationStrain By Continual NoiseTotalAccident DescriptionWAS BEND OVER VACUUMING FOR 30 SECONDS AND FELT PAIN IN BACKClaim Number: 1234567898AgeClass CodeDate of InjuryDate Reported to CarrierClose DateIn LitigationNature of InjuryBody PartCauseAccident DescriptionClaimant Name: Roger Martin52518302/22/201702/25/201706/10/2017NoSpc: StrainUpper Ext: Lower ArmStrain By LiftingConditioned Air & Service, Inc.ABC12345678907/01/2016 - 07/01/2017Bronze Age Insurance, Inc.Claim Examiner Terry ChandelierPhone Number (555) 555-5555Paid 917.71 1,409.51 87.96 0.00Reserved 0.00 0.00 0.00 0.00 2,415.18 0.00Claim Status:Location 001 Conditioned Air & Service, Inc.1234 South Bird Dr.,Anaheim, CA 92807MedicalIndemnityLoss Adj. ExpenseRehabSubrogationTotalClosed / IndemnityTotal Incurred 917.71 1,409.51 87.96 0.00 0.00 2,415.18Closed / IndemnityClaim Examiner Terry ChandelierPhone Number (555) 555-5555Paid 838.87 1,219.04 84.44 0.00Reserved 0.00 0.00 0.00 0.00 2,142.35 0.00Total Incurred 838.87 1,219.04 84.44 0.00 0.00 2,142.35PULLING FILTERS ONTO A ROOF, FELT PAIN ON RIGHT ARM.Claim Number: 1234567899Claimant Name: Larry BarberLocation 001AgeClass CodeDate of InjuryDate Reported to CarrierClose DateIn LitigationNature of InjuryBody PartCause36518302/16/201702/19/2017Accident DescriptionEE WAS HELPING WITH A CRANE AND STRAINED BACKClaim Status:Conditioned Air & Service, Inc.1234 South Bird Dr.,Anaheim, CA 92807NoSpc: StrainTrunk: Low Back (Lmbr/Lmbo-Sac)Strain By, NocMedicalIndemnityLoss Adj. ExpenseRehabSubrogationTotalOpen / IndemnityClaim Examiner Terry ChandelierPhone Number (555) 555-5555Paid 6,249.25 17,334.74 1,645.25 0.00Reserved 11,050.75 8,783.00 354.75 0.00 25,229.24 20,188.50Total Incurred 17,300.00 26,117.74 2,000.00 0.00 0.00 45,417.74
InsuredPolicy NumberPolicy PeriodAgentWorkers' Compensation Loss Analysis ReportKnights of Rohan Insurance CompanyValued as of:03/13/2017Conditioned Air & Service, Inc.ABC12345678907/01/2016 - 07/01/2017Bronze Age Insurance, Inc.4:58:34 pmLocation Summary001Conditioned Air & Service, Inc.1234 South Bird Dr., Anaheim, CA 92807Number of Claims:3Loss Type:PaidReservedTotal IncurredOpen gationTotal 8,005.83 19,963.29 1,817.65 0.00 11,050.75 8,783.00 354.75 0.00 29,786.77 20,188.50 19,056.58 28,746.29 2,172.40 0.00 0.00 49,975.27WSD 5030584 00
Knights of Rohan Insurance CompanyValued as of: 03/13/2017 4:58:41 pmWorkers' Compensation Loss Analysis ReportINSUREDInsuredAddressPolicy NumberPolicy PeriodCURRENT ACCOUNT SUMMARYConditioned Air & Service, Inc.1234 South Bird Dr., Anaheim, CA 92807Term PremiumEarned PremiumTotal Paid Losses and ExpensesOutstanding Losses and ExpensesSubrogationTotal Incurred Losses and ExpensesLoss RatioExperience ModificationTotal Number of ClaimsNumber of Medical ClaimsABC9876544567/01/2017 - 7/01/2018CONTACT INFORMATIONAgentAgency CodePhoneBronze Age Insurance, Inc.0000001(555) 555-5555Number of Indemnity Claims 151,379.00 93,954.50 0.00 0.00 0.00 0.000%110%0Open0Closed0OpenClosed00PAST ACCOUNT SUMMARYPaid Loss# Total # Open AdjustmentClaims Claims ExpensesPaidLossesOutstanding Total IncurredLosses and Losses and LossExpensesExpensesRatioPolicyNumberEffective 345678907/01/2016 07/01/2017 130,453.00 130,453.0031 1,817.65 27,969.12 20,188.50 49,975.2738%Total: 130,453.00 130,453.0031 1,817.65 27,969.12 20,188.50 49,975.2738%
CSR’s Phone: 555-555-5555 CSR’s Fax: 555-555-5555 SIC: 4651328. The insured needs a workers’ compensation policy : quote: and wants a : monthly: reporting option. (Hint: This will be a : direct bill: item for the insurance company) The insured is
The Workers' Compensation Act was enacted in 1915 to protect workers and outline the responsibilities of stakeholders in Pennsylvania's workers' compensation system. Today, more than 100 years later, the Depart - ment of Labor & Industry's Bureau of Workers' Compensation, the Workers' Compensation Appeal Board and
1. Virginia's Workers' Compensation System 1 2. Timeliness of the Workers' Compensation System 11 3. Fairness in the Workers' Compensation System 23 4. Appropriateness of Disease Presumptions 41 5. Establishing and Rebutting Virginia's Disease Presumptions 63 6. Preventing Fraudulent or Inaccurate Workers' 81 Compensation Benefits
You must file the DWC Form-005 if you do not have workers compensation insurance, or you have terminated your workers compensation insurance coverage. However, if your only employees are exempt from coverage under the Texas Workers Compensation Act (for example, certain domestic workers, and certain farm and ranch workers) you do not have to file.
a Workers' Compensation Claim for Compensation, which your Workers' Compensation attorney can assist you in filing. Can survivor benefits be denied or reduced? The same rules that make an employee eligible for Workers' Compensation benefits, apply in the case of a work-related injury that results in death. First, the employer must .
PHYSICIAN DISPENSING IN WORKERS’ COMPENSATION Financial Incentives vs. Medical Necessities Studies by the Workers Compensation Research Institute (WCRI) have shown that between the period of 2007 to 2011, there was a rapid growth in physician-dispensed pharmaceuticals for injured workers under states’ Workers’ Compensation plans. 2
purposes of workers' compensation insurance. Myth: I am a small employer with minimal revenue, so I will have my employees secure their own workers' compensation policy in order to save money. Reality: A business cannot require their employees to obtain their own workers' compensation insurance poli-cy. The cost of the workers' compen-
Sep 18, 2006 · Endorsement can be used to provide employees with voluntary compensation coverage, but not workers’ compensation coverage.2 Rule II. D. of the MA Manual describes voluntary compensation insurance as follows: Voluntary compensation insurance does not provide workers’ compensation coverage and is not available forFile Size: 272KB
30 Workers’ Compensation Compensation for Work-Related Vehicular Accidents An injured worker involved in a work-related accident while operating or occupying an employer’s vehicle will still look first to workers’ compensation for medical coverage. Wage loss benefits Workers’ compensation wage-loss benefits are calculated
