Liability Insurance Questionnaire- Brochure

WORKERS’ COMPENSATION QUESTIONNAIRE Please return this form by fax, mail, or email.4. FEIN #5. Please identify the owners and officers of your company by title and percentage of ownership:6. Please identify those owner who wish to be excluded from Workers’ Compensation coverage:I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms2b. City, State, Zipcode:2a. Mailing Address:1. Company Name:3. Please advise what payroll classifications appear on your current policy and provide payroll information(EXCLUDE ACTIVE OWNERS) – Please note state which coverage applies: Payroll Next 12 Mos.Classification Code #/Slate Payroll Last 12 Mos.123457. Please identify your Workers’ Compensation insurer for the past five years and policy number:Expiration Date (mm/dd/yyyy) Insurer Policy #123451 of 2If Yes, please identify insurer:10a. Please list all states where you have resident employees below.Additional information requested – Please send the following:1. Four years formal insurance reports or a detailed letter confirming loss history and agreeing to obtain these reports as soon as possible.2. A photocopy of information from your current insurer which identifies your current experience modification.3. A copy of your Health and Safety Plan. I CERTIFY THAT THE STATEMENTS ABOVE ARE CORRECT AND TRUE.Signature over printed name of person completing the questionnaire:Phone Number (ex: 000-000-0000):E-mail:Date (mm/dd/yyyy):8. Have you ever had a loss?Yes No9. Do you presently have an employee health insurance plan?Yes No11. Any over the water exposure or USL&H needed:Yes No10b. Do you have any employees which travel outside of the Country on business?Yes NoI n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms2 of 2 1 Company Name: 2a Mailing Address: 2b City State Zipcode: Classification Code Slate1: Payroll Next 12 Mos1: Payroll Last 12 Mos1: Classification Code Slate2: Payroll Next 12 Mos2: Payroll Last 12 Mos2: Classification Code Slate3: Payroll Next 12 Mos3: Payroll Last 12 Mos3: Classification Code Slate4: Payroll Next 12 Mos4: Payroll Last 12 Mos4: Classification Code Slate5: Payroll Next 12 Mos5: Payroll Last 12 Mos5: 4 FEIN: 5 Please identify the owners and officers of your company by title and percentage of ownership: 6 Please identify those owner who wish to be excluded from Workers Compensation coverage: Expiration Date mmddyyyy1: Insurer1: Policy 1: Expiration Date mmddyyyy2: Insurer2: Policy 2: Expiration Date mmddyyyy3: Insurer3: Policy 3: Expiration Date mmddyyyy4: Insurer4: Policy 4: Expiration Date mmddyyyy5: Insurer5: Policy 5: 8 Have you ever had a loss: 9 Do you presently have an employee health insurance plan: If Yes please identify insurer: 10a Please list all states where you have resident employees below: 10b Do you have any employees which travel outside of the Country on business: 11 Any over the water exposure or USLH needed: Phone Number ex 0000000000: Email: Date mmddyyyy: Clear Form: