KRM SUPPLEMENTAL APPLICATION
Insured: ______Eff Date: ______FEIN NO. ______
Contact Name & Title: ______Tel. No.: ______Fax No.: ______
INSURED HISTORY:
Years in business:______if less than 5 number of years in trade______No. of locations ______
Description of Operations ______
Out of state exposure: p Yes p No If yes, name of states: ______Foreign Travel: p Yes p No
Present number of employees: Full-time employees ______Part-time ______Seasonal ______Volunteers______
Percent of employee turnover in the last 12 months Full-time ______Part-time ______
Employee staffing expectation over the next 12 months Full-time ______Part-time ______
Average hourly wage: Full-time $______Part-time $______Any Piece work compensation:______
Benefits provided – are ALL employees eligible p Yes p No If not then who is eligible? ______
% paid by employer % of participation
Group Health p Yes p No ______
Paid sick leave p Yes p No ______
Vacation p Yes p No ______
Retirement / Pension Plan p Yes p No ______
Name of Healthcare provider: ______
Provide name of clinic, physician, or emergency room used for work place related injury: ______
Full-time nurse maintained on staff: p Yes p No
CPR training provided p Yes p No
Indicate the safety activities currently established and practiced regularly:
Is Owner active in daily operations p Yes p No, if yes duties performed:______
Safety program / IIPP in use compliant with SB 198 p Yes p No
Return to light duty plan p Yes p No Includes full wages p Yes p No
Return to Full-time modified work plan p Yes p No
Designated Full-time safety director p Yes p No Name: ______
Safety meetings held for all employees p Yes p No Frequency of meetings ______
Safety training held for all employees p Yes p No Incentive program for employees p Yes p No
Slip and Fall Prevention Program in place p Yes p No
Hazardous Materials Communication program in place p Yes p No
Personal Protective safety equipment provided for all employees p Yes p No If yes, what type:______
Supervisors are held accountable for injuries / accidents p Yes p No
Accident investigation program in place p Yes p No
HIRING PRACTICES:
Employment application p Yes p No Drug/substance abuse p Yes p No
Reference checks p Yes p No Audiometric testing p Yes p No
Motor Vehicle Record check p Yes p No Pre/Post employment physical p Yes p No
Volunteer labor used p Yes p No Pathogenic test (i.e. lead) p Yes p No
Temporary labor used p Yes p No Orthopedic back test p Yes p No
OPERATIONS:
Hours of operation: ______to ______No. of daily shifts:______No. of days per week:______
Operation includes delivery p Yes p No No. of authorized drivers ______No. of vehicles ______
Frequency of delivery: Daily p Weekly p Other p ______
Delivery radius: < 50 miles p 51-100 miles p 101-250 miles p >250 miles p
Frequency of MVR checks ______Participation in CHP Pull program p Yes p No
Driver acceptability standards have been established p Yes p No
Vehicle inspection / maintenance program p Yes p No Frequency ______
Vehicle maintenance is performed by employees p Yes p No
Employees take vehicles home at night p Yes p No REVISED 9/05
Page 1
PAYROLL AND PREMIUM HISTORY:
Payroll : Current Yr. ______Premium: Current Yr. ______
1st Prior Yr. ______1st Prior Yr. ______
2nd Prior Yr.______2nd Prior Yr.______
3rd Prior Yr.______3rd Prior Yr.______
CATASTROPHE EXPOSURE:
Does insured work within 2 miles of the following building or facilities:
Government or Military base p Yes p No
Financial Institutions including national/regional stock exchange p Yes p No
Sport Stadiums/Arenas and Theme Parks p Yes p No
Major Bridges, Tunnels or Dams p Yes p No
Utilities or Power Generation Plants p Yes p No
Transportation Hubs, Railroads, Airports or Shipping p Yes p No
Historic/Symbolic buildings, monuments or parks p Yes p No
EXPOSURE INFORMATION – PREMISES - FIXED LOCATION - EMPLOYEES
Total number of employee’s:______
State / Location# / Payroll / Total # of Employees / # of
Shifts / Maximum #
of Employees
Per Shift / Type of
Building (See List
Below) / Year
Built / # of
Stories / Floors
Occupied
$
$
$
$
$
$
$
$
If additional locations exist please included on a separate form.
Type of Building: (1.) Steel 3 stories or greater (2.) Frame 3 stories or less (3.) Concrete tilt up
MEDICAL PROVIDER NETWORK COMPLIANCE:
1. IF THIS APPLICATION IS NEW BUSINESS TO PRAETORIAN OR SIRIUS AMERICA/DELOS:
Has the Insured previously participated in a Medical Provider Network? p Yes p No
Is the Insured willing to participate in the Praetorian/Sirius America/DELOS/TMC MPN? p Yes p No
2. IF THIS APPLICATION IS RENEWAL BUSINESS TO PRAETORIAN OR SIRIUS AMERICA/DELOS:
Has the Insured implemented the Praetorian/Sirius America/DELOS/TMC MPN? p Yes p No
If yes, when?
If not, will the Insured implement the Praetorian/Sirius America/DELOS/TMC MPN during the next policy term?
p Yesp No
Signature:______Title:______Date:______
Page 2
***THIS FORM MUST BE FILLED OUT IF IT APPLIES TO THE INSURED***
HOTEL / MOTEL:
Number of guest rooms: ______Room rate: Under $50 p $50-74.95 p $75-99 p Over $100 p
Food service: Operate own: p Yes p No Subcontract: Restaurant p Bar p Both p
Gross receipts: Food ______% Liquor ______%
Entertainment: p Yes p No Lounge: p Yes p No Armed Security: p Yes p No
Operation: Year round p Seasonal p Conference center: p Yes p No
Shuttle service: p Yes p No How many vans: ______
How are maids compensated: Salary p Hourly wage p Flat rate per room p
Who flips the mattresses and how are they turned: ______
RETAIL / WHOLESALE:
Gross receipts: Wholesale ______% Retail ______%
Compensation: Flat salary ______Hourly wage ______
Outside sales employees: p Yes p No
Lifting exposure or repackaging: p Yes p No Lbs: ______
If yes, describe? ______
Type of merchandise: ______
Commission ______
Is there assembly: p Yes p No
MANUFACTURING:
Machine guarding: Point of operation: p Yes p No
Computer operated equipment: p Yes p No
Material handling exposure: p Yes p No
Off premises operations: p Yes p No Percentage ______
Drive mechanism: p Yes p No Moving Parts: pYes p No
Lifting: p Below 50 lbs. p Above 50 lbs. ______
Where / What: ______
TYPE OF MACHINES USED?______
SERVICE STATIONS / AUTO REPAIR SHOPS / TRANSMISSION SHOPS:
Hours of Operation ______
Gas operation: p Full Service p Self service
Repair operation: p Yes p No
p Tire repair/installation :p Split Rim p Over 1-ton truck
Towing: p Yes p No Contract tow: p Yes p No
Mini-Market: p Yes p No Liquor sold? p Yes p No
Bullet proof cashier booth: p Yes p No
Drop safe or registers: p Yes p No
Car Wash: p Yes p No If yes, p self serve p full serve
Access to freeway: p 0-1 mile p 1-2 miles p 2+ miles
ATTORNEYS:
What type of law: ______
Any criminal law: p Yes p No
Any insurance law: p Yes p No
RESTAURANT:
Average Entrée Price: ______
Liquor Receipts (% of gross receipts) ______
Separate Lounge: p Yes p No
Twenty-four hour operation: p Yes p No
Number of: Hosts _____ Wait-staff ____ Cooks ______
Bartenders _____
Entertainment:p Yes p No If yes, please provide details:
Take-out: p Yes p No % of revenues ______
Catering p Yes p No % of revenues ______Delivery p Yes p No % of revenues ______
Valet Parking p Yes p No
Radius of delivery area ______
______
APARTMENT OWNER OR OPERATOR:
List of operations sub-contracted to others: ______
Any tenants perform sub-contracted operations for you? p Yes p No If yes, please list: ______
The following items are maintained and kept current for all sub-contractors:
Certificate of workers’ compensation insurance p Yes p No
Copy of each sub-contractor’s license number p Yes p No
List of current sub-contractors and contractor’s license numbers:______(If more than 3 provide a separate list)
Page 3
***THIS FORM MUST BE FILLED OUT IF IT APPLIES TO THE INSURED***
CONTRACTORS:
Contractors License Number:______
Percentage of new construction: Residential % Commercial % Industrial %
Percentage of remodeling: Residential % Commercial % Industrial %
Percentage of repair work: Residential % Commercial % Industrial %
Percentage of work subcontracted: %
Any work performed above 2 stories: p Yes p No If yes, explain______
Any Roof Exposure: p Yes p No If yes, explain______
Details of Interior and/or Exterior work performed ______
Any use of Cranes: p Yes p No If yes, explain ______
Any use of Scaffolds: p Yes p No If yes, are the ee’s certified?______
Any Excavation exposure: p Yes p No If yes, explain depth______
Are deliveries made: p Yes p No Frequency: Daily p Weekly p Other:______
Delivery radius: Under 50 miles p 50-100 milesp Over 100 miles p
Vehicles owned: p Yes p No If yes, take home: p Yes p No
Vehicle maintenance program: p Yes p No
MVR “Pull” program: p Yes p No If yes, how often______
Any changes in operations in the last 5 years: p Yes p No If yes, describe:______
Condition of equipment: Excellent p Good p Poor p
Any job site security provided: p Yes p No If yes, describe:______
FARMS:
Crops Grown / Avg. Acreage / Harvested Mechanically / Type of EquipmentYES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
1: How many acres: 160 or lessp 161-499p 500-999p 1,000+p
2: Housing Provided: p Yes p No If so, how many employees
3: Transportation of employees: p Yes p No How: Van p Bus p Airplane p Otherp
Frequency: Dailyp Weeklyp Monthlyp Radius
4: Use Labor Contractor: p Yes p No
5: Employees pay: Hourly rate Piece rate Combination Other
6: Operation outside of California: p Yes p No
7: Dairy Barn: Elevated p Carousel p Flat p Other ______
a) Number of Milking cows ______
b) Number of Bulls Number of Bulls 3 years old & older: ______
c) Outside Veterinary Services: p Yes p No
d) Artificial Insemination: p Yes p No Subcontracted: p Yes p No
e) Hoof trimming: p Yes p No Subcontracted p Yes p No
f) De-horn: p Yes p No Subcontracted p Yes p No
8: Does insured harvest crops for others: p Yes p No If so, own equipment used: p Yes p No
TRUCKING EXPOSURES:
1. Commodities Hauled – Breakdown by % of Revenue:______
2. Type of Equipment – Type of Number of Vehicles:
p Flatbed_____ pTractor Trailer_____ p Double Trailer_____ pTank_____
p Refrigerated_____ p Other______
3. Do drivers load and unload cargo? p Yes p No If yes, how often:____% palletized loads? p Yes p No
4. Type of Carrier p Truckload(TL) p Less than Truckload (LTL)
5. Number of Drivers:______b. Average age of Drivers:______c. Average age of Vehicles:______
Page 4
COMPLETE PAGE #5 IF MORE THAN 100 EMPLOYEES PER LOCATION
Reinsurance Information: Must be completed for each location with 100+ employees
Location #1
Street address: ______City: ______State: ___ Zip code: ______
Number of employees at this location: ______Hours of operation: ______Number of shifts: _____
Type of construction: Frame (Code 1)___ Joisted Masonry (Code 2) ___ Non-combustible (Code 3) ___
Masonry non-combustible (Code 4) ___ Modified fire resistive (Code 5)___ Fire resistive (Code 6) ___
Seismically retrofit? p Yes p No If yes – year completed: ____
Age of building: _____ Number of floors: ___ Specific floors occupied: ______
Location is: Single building: __ Multi-building: __ Urban: ___ Suburban: ___ Rural: ___
Class codes: ______
Payroll by class code: ______
Reinsurance Information: Must be completed for each location with 100+ employees
Location #2
Street address: ______City: ______State: ___ Zip code: ______
Number of employees at this location: ______Hours of operation: ______Number of shifts: _____
Type of construction: Frame (Code 1)___ Joisted Masonry (Code 2) ___ Non-combustible (Code 3) ___
Masonry non-combustible (Code 4) ___ Modified fire resistive (Code 5)___ Fire resistive (Code 6) ___
Seismically retrofit? p Yes p No If yes – year completed: ____
Age of building: _____ Number of floors: ___ Specific floors occupied: ______
Location is: Single building: __ Multi-building: __ Urban: ___ Suburban: ___ Rural: ___
Class codes: ______
Payroll by class code: ______
Reinsurance Information: Must be completed for each location with 100+ employees
Location #3
Street address: ______City: ______State: ___ Zip code: ______
Number of employees at this location: ______Hours of operation: ______Number of shifts: _____
Type of construction: Frame (Code 1)___ Joisted Masonry (Code 2) ___ Non-combustible (Code 3) ___
Masonry non-combustible (Code 4) ___ Modified fire resistive (Code 5)___ Fire resistive (Code 6) ___
Seismically retrofit? p Yes p No If yes – year completed: ____
Age of building: _____ Number of floors: ___ Specific floors occupied: ______
Location is: Single building: __ Multi-building: __ Urban: ___ Suburban: ___ Rural: ___
Class codes: ______
Payroll by class code: ______
Reinsurance Information: Must be completed for each location with 100+ employees
Location #4
Street address: ______City: ______State: ___ Zip code: ______
Number of employees at this location: ______Hours of operation: ______Number of shifts: _____
Type of construction: Frame (Code 1)___ Joisted Masonry (Code 2) ___ Non-combustible (Code 3) ___
Masonry non-combustible (Code 4) ___ Modified fire resistive (Code 5)___ Fire resistive (Code 6) ___
Seismically retrofit? p Yes p No If yes – year completed: ____
Age of building: _____ Number of floors: ___ Specific floors occupied: ______
Location is: Single building: __ Multi-building: __ Urban: ___ Suburban: ___ Rural: ___
Class codes: ______
Payroll by class code: ______Page 5