Questionnaire Selection Coverage List

Category: Casual and Artisan Contractors Risk: Carpenters

GENERAL CLIENT INFORMATION

Account: ___________________________________________________________

Account Number: ____________________________________________________

Agency: ____________________________________________________________

Agency Number: _____________________________________________________

Producer: __________________________________________________________

Producer Number: ___________________________________________________

BUSINESS LEGAL NAME MAILING ADDRESS

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Legal Entity:

___ Individual ___ Corporation ___ Partnership
___ Joint Venture ___ Sub-S Corp. ___ Not for profit
___ Limited Liability

SIC CODE(s) ___________________________________

FEDERAL ID NUMBER ____________________________

YEARS IN BUSINESS ___________________________

Number of years under present management: ___ years

Number of years experience of owner: ___ years

Number of years experience of manager: ___ years

Has the risk ever been involved in a bankruptcy procedure? ___ Yes ___ No

If yes, explain: _____________________________________________________

Names of subsidiary companies or joint ventures that are not part of this
application: ________________________________________________________

__________________________________________________________________

The applicant’s primary operations are: ____________________________________

_____________________________________________________________________

_____________________________________________________________________

The applicant’s secondary and incidental operations are: ______________________

_____________________________________________________________________

_____________________________________________________________________

The applicant used to be involved in the following operations but they have been discontinued:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

The hours of operation are: _____________________________________________

Number of days the business is open per week: _______________

Is this a seasonal operation? ___ Yes ___ No

What is the season? From _____________ To _____________

Does the applicant have a safety program? ___Yes ___No

Name of safety director: ____________________________________________

Phone number of safety director:_________________________________

Attach copy of safety program.

Does the applicant have a disaster plan?_______

Name of disaster coordinator:_________________________________

Phone number of disaster coordinator:________________________

Attach a copy of the disaster plan.

WORKERS COMPENSATION

OPERATIONS

States where anticipated workplaces will begin within next twelve (12) months:

_________________________________________________________________

_________________________________________________________________

Are operations performed on public works projects outside the United States? ___ Yes ___ No

If yes, describe:____________________________________________________

_________________________________________________________________

NOTE: If yes, consider including the Foreign Operations Supplement.

Are operations performed on docks, piers, wharves, etc., along navigable waters? ___ Yes ___No

If yes, describe:________________________________________________

_________________________________________________________________

Note: If yes, consider including the Federal Workers/Longshore And Harbor Workers Questionnaire.

Any work performed on barges, vessels, bridges over water? ___ Yes ___ No

Note: If yes, consider including the Federal Workers/Longshore And Harbor Workers Questionnaire.

Are operations performed on the outer continental shelf? ___ Yes ___ No

If yes, describe:________________________________________________

_________________________________________________________________

Note: If yes, consider including the Federal Workers/Longshore And Harbor Workers Questionnaire.

Are operations performed on U.S. defense bases? ___ Yes ___ No

If yes, describe:________________________________________________

_________________________________________________________________

Note: If yes, consider including the Federal Workers/Longshore And Harbor Workers Questionnaire.

Are operations performed in monopolistic workers compensation states? ___ Yes ___ No

Note: If yes, consider including the Employers Liability - Stop Gap questionnaire.

Does the risk own, or jointly own with another person, partnership or corporation, operate or lease aircraft/watercraft? ___ Yes ___ No

Note: If aircraft exposure is present, consider including the Aircraft Ownership Supplement. If watercraft exposure is present, consider including the Ship or Boat Ownership Supplement.

EMPLOYEES

Do operations involve migrant laborers? ___ Yes ___ No

If yes, describe:________________________________________________

_________________________________________________________________

Do employees ever travel outside the United States to work? ___ Yes ___ No

If yes, describe:____________________________________________________

_________________________________________________________________

NOTE: If yes, consider including the Foreign Operations Supplement.

Are any employees exempt from workers compensation statutes in any jurisdictions in which operations are conducted?

(i.e., casual laborers, volunteers, etc.)? ___ Yes ___ No

If yes, describe:__________________________________________________________

________________________________________________________________________

Do any employees predominantly work at home? ___ Yes ___ No

If yes, describe employee job functions and safety procedures for those employees:

________________________________________________________________________

________________________________________________________________________

Does the applicant employ persons from a day labor pool? ___ Yes ___ No

If the jobsite is at a distance from the office, what percentage of the labor is local and what percentage is from the applicant's normal labor force?

________% Local _______% Full time

MANAGEMENT

Does the applicant obtain work permits when the law requires them? ___ Yes ___ No

Is there an organizational policy concerning the number of key employees who travel together? ___ Yes ___ No

If yes, attach copy.

If risk employs subcontractors, what procedure does risk use to monitor the timely receipt of certificates of insurance? ___________________________________________________________________

___________________________________________________________________

Is all machinery and equipment properly guarded and secured? ___ Yes ___ No

Are employees trained prior to operating any machinery and equipment? ___ Yes ___ No

Are employees trained in the proper cleaning techniques for machinery and equipment? ___ Yes ___ No

If yes to the training questions, attach a copy of the training procedure and documentation method used to ensure adequate training.

Are all walk-in freezers, cold storage boxes and other automatic locking storage areas equipped with a pass-type latch that can be opened from the inside when the outside is locked? ___ Yes ___ No

Are first aid kits provided? ___ Yes ___ No

Is at least one employee (on duty) trained in administering first aid? ___ Yes ___ No

Is at least one person at each jobsite trained in first aid? ___ Yes ___ No