AmCheck - National Broker Services Corporation

When you need worker's compensation insurance and you need it fast!

Workers Compensation Extended Questionnaire

REQUESTED EFFECTIVE DATE OF COVERAGE (MM/DD/YYYY)

SECTION 1: INSURED/COMPANY INFORMATION

Company Name

Doing Business As

Company Website

Federal EIN State TIN Date Business Started (MM/DD/YYYY)

Current Payroll Method

Type of Company:
	Individual
	Partnership
	Corporation
	LLC
	Non-Profit Entity
	"S" Corp
	Government Entity
	Religious Org.

Business Street Address (No PO Box) Address 2

City State Zip +4

Salutation First Name Last Name Phone "No Dashes" ext.

Email Address Fax "No Dashes" Cell Phone
Check here if you are an insurance agent acting on behalf of a client

Describe this company's business objectives and operational details.

Hours of Operation:
From	am pm
To	am pm

For Restaurants Only:

Is your business a restraurant (Yes)

SECTION 2: OWNER/CORPORATE OFFICER INFORMATION

Owner/Corporate Officer Name	Title	Ownership Percentage	Is the owner/officer included in or excluded from policy coverage?			Annualized Income	Class Code
				Included	Excluded	$
	Description of Duties:
				Included	Excluded	$
	Description of Duties:

Add More Officers

SECTION 3: WORKERS COMPENSATION COVERAGE HISTORY

"Has this company had previous workers compensation insurance coverage?" Yes or No


	Reason For No Previous Coverage

Policy Term	Insurance Company	Policy Number	Annual Premium	E-MOD	# Claims
From : To :			$
From : To :			$
From : To :			$

SECTION 4: REQUESTED LIABILITY LIMITS (select one)


Each Accident	$100,000	$500,000	$1,000,000
Disease - Policy Limit	$500,000	$500,000	$1,000,000
Disease - Each Employee	$100,000 Default Amounts	$500,000 Subject to higher premiums	$1,000,000 Subject to higher premiums

SECTION 5: INSURED EMPLOYEE INFORMATION

Step 1: List all locations where insured workers are employed. Include home addresses for employees based out of their homes.

Work
Location

Physical Address:
City: State: Zip:

Location Office in a Home Factory/Warehouse
Description: Commercial Office Client Location

Add More Locations

Step 2: List all workers to be insured with this policy request by job title within each location.
DO NOT include Owners or Corporate Officers if already listed as 'Included' in Section 2

Job Title:	Work Location #:	Number of Employees: FT PT	Total Gross Annual Payroll:	Class Code:
Detailed Description of Duties:
Machinery, Materials, and Equipment Used:

Add More Job Titles

SECTION 6: GENERAL INFORMATION

GENERAL INFORMATION			EXPLANATION FOR ALL "YES" ANSWERS
1. Does applicant own, operate or lease aircraft/watercraft?	Yes	No
2. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, or transporting of hazardous materials?	Yes	No
3. Any work performed underground or above 15 feet?	Yes	No
4. Any work performed on barges, vessels, docks, bridges over water?	Yes	No
5. Is applicant engaged in any other type of business?	Yes	No
6. Are sub-contractors used? If “yes”, give % of work subcontracted	Yes	No
7. Any work sublet without certificates of insurance?	Yes	No
8. Is a formal Written Safety Program in operation?	Yes	No
9. Any group transportation provided?	Yes	No
10. Any employees under 16 or over 60 years of age?	Yes	No
11. Any seasonal employees?	Yes	No
12. Is there any volunteer or donated labor?	Yes	No
13. Any employees with physical handicaps?	Yes	No
14. Do employees travel out of state?	Yes	No
15. Are athletic teams sponsored?	Yes	No
16. Are physicals required after offers of employment are made?	Yes	No
17. Any other insurance with this carrier?	Yes	No
18. Any prior coverage declined, cancelled, non-renewed (last 3 yrs?)	Yes	No
19. Are employee health plans provided?	Yes	No
20. Is there a labor interchange with any other business/subsidiary?	Yes	No
21. Do you lease employees to or from other employers?	Yes	No
22. Do any employees predominantly work at home?	Yes	No
23. Any tax liens or bankruptcy within the last 5 years?	Yes	No
24. Any undisputed and unpaid work comp premium due from you or any commonly managed or owned enterprises?	Yes	No

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