I. APPLICANT/BROKER INFORMATION
Name of Applicant
/ Today’s Date:
/ Effective Date of Coverage:
Head Office Address
Brokerage Firm & Address
Broker Contact
/ Telephone
( ) / Fax
( )
Date first began operating in the United States:
Description of Operations (Specifically detail US operations.) Attachment included? Yes No
1. Foreign Coverage (outside North America) required? Yes No If yes, please describe where employees travel to, average length of stay, number of employees travelling at any one time overseas, and extent of work performed overseas:
2. Federal Coverage Requirements, if any:
Maritime: Yes No If yes, please explain:
Federal Employers’ Liability Act: Yes No If yes, please explain:
Defense Base Act: Yes No If yes, please explain:
OuterContinental Shelf Lands Act: Yes No If yes, please explain:
United States Longshore & Harbor Workers Act: Yes No If yes, please explain:
U.S. Locations of Applicant Attachment included? Yes No
Loc. No. / Legal Name / Street, City, County, Zip Code / Federal Employer
ID No. (FEIN)
1
2
3
4
5
II. UNDERWRITING INFORMATION
Projected Payroll Information (“Class Code” = Job Description/Classification)
State / Loc. No. / Class Code / Description of Duties / Projected Payroll
NCCI Interstate Experience Modifier
Intrastate Experience Modifiers
CA
DE
MI
NJ
PA
Expiring Program Premium
$ / Expiring Program Payroll
$
III. HISTORICAL PAYROLL (Not Applicable if Interstate and/or Intrastate Modifier worksheet are attached)
Payroll Period / Total Payroll (All U.S. Locations)
IV. HISTORICAL LOSS INFORMATION
1. Carrier Loss Runs: All applications must contain at least 5 years loss history with current valuation dates.
2. If no reported losses, provide a statement on company letterhead detailing the period of time with no reported claims.
3. Detailed Summary: Please provide a detailed summary of all claims with an incurred value of $25,000 or greater.
V. SERVICE INFORMATION (Required in order to bind coverage)
Payroll Audit Contact Name
/ Phone Number
( )
Address
/ Fax Number
( )
Claims Contact Name
/ Phone Number
( )
Address
/ Fax Number
( )
Loss Prevention Contact Name (where applicable)
/ Phone Number
( )
Address
/ Fax Number
( )
VI. General information (please explain all “yes” responses) Y/N
1. Does the client own, operate, or lease aircraft or watercraft? / Yes No
2. Is any work performed underground or above 15 feet? / Yes No
3. Is any work performed on barges, vessels, docks, or bridges over water? / Yes No
4. Are Sub-Contractors used? (if Yes give % of work subcontracted) / Yes No
5. If Sub-Contractors are used, are certificates of insurance obtained? / Yes No
6. Does the client employ any person under 16 or over 65 years of age? / Yes No
7. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or tranporting of hazardous material? / Yes No
8. Is the client engaged in any other type of business? / Yes No
9. Is a written safety program in place? If yes, may we have a copy? / Yes No
10. Is group transportation provided? / Yes No
11. Does the client employ any seasonal staff? / Yes No
12. Does the client employ any volunteers? / Yes No
13. Are athletic teams sponsored by the company? / Yes No
14. Any prior WC coverage declined, cancelled, or non-renewed in the last three years? / Yes No
15. Do any employees perform work for other businesses or subsidiaries? / Yes No
16. Does the client lease employees to or from another employer or PEO? / Yes No
17. Do the majority of employees work from home? If yes, # of employees: / Yes No
18. Any bankruptcy within the past five years? / Yes No
19. Are nano materials used in any of your US processes? (Y/N) / Yes No
20. Are chemicals used in any part of your US processes? (Y/N) / Yes No
21. Are biological agents (bacteria, viruses, fungi or other microorganisms) used in any part of your US processes? (Y/N) / Yes No
22. Are physical agents (noise, vibration, radiation, or temperature extremes) used in any part of your US processes or would any of your US employees be exposed? (Y/N) / Yes No
LIBERTY MUTUAL GROUP INC.
PLEASE EMAIL THIS APPLICATION TO:
PLEASE FORWARD INQUIRIES TO:
AMY MEHTA
(416) 307-4664 PHONE
This document was issued in the course of the Liberty Mutual Group’s insurance business in the United States and any policy to be issued pursuant to this application shall be governed by and comply with the laws of the United States. Policies may be written by any of the following members of the Liberty Mutual Group: Liberty Mutual Insurance Company, Liberty Mutual Fire Insurance Company, Liberty Insurance Corporation, LM Insurance Corporation and The First Liberty Insurance Corporation
WC Application/1 : 2014/13/18 Page 1 of 4