Workers Compensation Form.
1501 Westcliff Dr. Suite 301
Newport Beach, CA. 92660
Tel: (877) 700- NEWS
Fax: (949) 554-0250
Email: Info@newsinsurance.com
Web: www.newsinsurance.com
APPLICANT INFORMATION
Quote Date :
First Name :
Last Name :
Location :
City : State : Zip Code :
Home No. :
Businness No. : * Ext.
E-Mail. :
Current Policy Expiration Date :
Social Security No. :
City : State : Zip Code :
Year in Business :
SIC :
Federal Employer ID #
LOCATION
  Street / City / County / State / Zip Code
Location 1 :
Location 2 :
Location 3 :
Location 4 :
 
RATING INFO
State Location# Class
Code		 Describe
Code		 Categories / Duties /Classifications # Employee Estimated Annual
Remuneration 		Rate Estimated Annual Premium
Full Time Part Time
 
PRIOR CARRIER INFORMATION/LOSS HISTORY
Provide information for the past 5 years.
Year
Carrier & Policy #
Annual Premium
MOD
# Claims
Aount Paid
Reserve
CO:
POL#:
CO:
POL#:
CO:
POL#:
CO:
POL#:
 
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS

Give comments and descriptions of business, operations and products.:
Manufacturing - Raw Materials, Processes, Products, Equipment, Contrator
Type of work - Sub-Contracts
Mercantile - Merchandise, Customers, Deliveries
Service - Type, Location
Farm - Acreage, Animals, Machinery, Sub-Contracts

 
INDIVIDUALS INCLUDED/EXCLUDED
Partners, officers, relatives to be included or excluded. (Remuneration to be included must be part of rating information section.)
State
Location#
Name
Date of Birth
Title/
Relationship
ownership
%
Duties
Inc/Exc
Class
Code
Remun-
aration
 
PREMISES INFORMATION
Location :
City : State : Zip Code :
  Owner Tenant
Nature of Businness/Description of Operations by Premises :
 
GENERAL INFORMATION
  Explain all "Yes" responses Yes No
1 Does applicant own, operate or lease aircraft/watercraft?
2 Do/have past, present or dicsontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tnaks, etc)
3 Any work performed underground or above 15 feet?
4 Any work performed on barges, vessels, docks, bridge over water?
5 Is applicant engaged in any other type of business?
6 Are sub-contractors used? (If yes, givve % of work subcontracted)
7 Any work sublet without certificates of Ins.?
8 Is a written safety program in operation?
9 Any group transportation provided?
10 Any employees under 16 or over 60 years of age?
11 Any seasonal employees?
12 Is there any volunteer or donated labor?
13 Any employees with physical handicaps?
14 Do employees travel out of state?
15 Are athletic teams sponsored?
16 Are physicals require after offers of employment are made?
17 Any other insurance with this insurer?
18 Any prior coverage declined/cancelled/non-renewed within the last three years? Not applicable in MO
19 Are employee health plans provided?
20 Is there a labor interchange with any other business/subsidiary?
21 Do you lease employees to or from other employers?
22 Do any employees predominantly work at home?
23 Any tax liens or bankruptcy within the last 5 years?
24 Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? If yes, explain including entity names(s) and policy numbers(s).

Applicable in Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claims containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, TN or VT; in C, LA, ME and VA, insurance benefits may also be denied)

Remarks:
   
Inspection: Phone:
  Name:
  Email:
Acctng Record : Phone:
  Name:
  Email:
Claims Info: Phone:
  Name:
  Email:
 
NATURE OF BUSINESS / DESCRIPTION OF OPERATION
Nature of Businness/Description of Operations :
 
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