Address of Properties (if different from above)
2nd Address (street,city,zip)
3rd Address (street,city,zip)
4th Address (street,city,zip)

Company Information
Type of Company	Individual* Partnership Corporation S-Corporation Other
* If Individual	Owners Name: Social Security#: Spouses Name: Social Security#:
Years in Business
License Number
NCCI Number
Other Rating Bureau ID Number
Total Gross Receipts
Employees Payroll
Nature of Business operations

Rating Information
Location	Class Code	Categories, Duties	# of Employees	Estimated Annual Remuneration

Individuals to be Included or Excluded
Person	Name	Date of Birth	Title Relationship	Ownership %	Duties	Inc/Exc	Renumeration
1
2
3
4

Prior Carrier Information / Loss History
Year	Carrier	Policy #	Annual Premium	MOD	# Claims	Amount Paid	Reserve

General Information (explain all "yes" answers in remarks)
Yes No	1. Does the applicant own, operate or lease Aircraft/Watercraft?
Yes No	2. Do/have past, present or discontinued operations involve(d) storing, treating, discarging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)
Yes No	3. Any work performed underground or above 15 feet?
Yes No	4. Any work performed on barges, vessels, docks, bridge over water?
Yes No	5. Is applicant engaged in any other type of business?
Yes No	6. Are sub-contractors used?
Yes No	7. Any work sublet without certificate of Insurance?
Yes No	8. Is a formal 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 part time or 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 insurer?
Yes No	18. Any prior coverage declined/cancelled/non-renewed (last 3 years)?
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?

Contact Information (Name & Phone Number)
Inspection
Accounting Records
Claims Info

Remarks and Comments

Reporting Method
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