Frankel & Associates Worker's Compensation Application : Workers Compensation : Work Compensation : California Workmans Comp : Long Term Disability Insurance

Frankel & Associates Worker's Compensation Application
Please fill out the following application to the best of your abilities. In order to receive an accurate quote we will also need loss runs from your previous insurance (if any).
Contact Information
Contact Name (First & Last): *
Contact Phone Number: *
Contact Email: *
Business Information
Legal name of Company *
Entity Type
FEIN# *
Business Address: *
Please explain your business operations. What is it that you do, exactly?
Please list all owners/officers, the % of the company owned, title and if they are to be included or excluded from coverage. *
Please provide the number of employees and annual estimated payroll. Categorize them by job type (Clerical, Manual Labor etc.) * (i.e.) 5 Clerical Employees @ 125K
Please provide dates, policy numbers and the company any prior policies were with.
Underwriting Questions
Does the applicant own, operate or lease aircraft or watercraft? *	Yes No
Any storing, treating or any other involvement with hazardous materials?	Yes No
Any work performed underground or above 15 feet? *	Yes No
Any work performed on barges, vessels, docks, bridges or over water? *	Yes No
Is there any work sublet without certificates?	Yes No
Is there a formal safety program in operation?	Yes No
Is there any group transportation provided?	Yes No
Are there any employees under 16 or over 60 years of age?	Yes No
Is there any volunteer or donated labor?	Yes No
Do any employees travel out of state for business purposes?	Yes No
Has any prior coverage been declined, cancelled or non-renewed in the last 3 years?	Yes No
Do you lease employees to or from other employers?	Yes No
Please include anything out of the ordinary or any remarks that you feel are relavent.


Contact Name (First & Last): *
Contact Phone Number: *
Contact Email: *

Legal name of Company *
Entity Type
FEIN# *
Business Address: *
Please explain your business operations. What is it that you do, exactly?
Please list all owners/officers, the % of the company owned, title and if they are to be included or excluded from coverage. *
Please provide the number of employees and annual estimated payroll. Categorize them by job type (Clerical, Manual Labor etc.) *
Please provide dates, policy numbers and the company any prior policies were with.

Does the applicant own, operate or lease aircraft or watercraft? *
Any storing, treating or any other involvement with hazardous materials?
Any work performed underground or above 15 feet? *
Any work performed on barges, vessels, docks, bridges or over water? *
Is there any work sublet without certificates?
Is there a formal safety program in operation?
Is there any group transportation provided?
Are there any employees under 16 or over 60 years of age?
Is there any volunteer or donated labor?
Do any employees travel out of state for business purposes?
Has any prior coverage been declined, cancelled or non-renewed in the last 3 years?
Do you lease employees to or from other employers?
Please include anything out of the ordinary or any remarks that you feel are relavent.