Specialty Workers Compensation Division

AIG

WC Supplemental Application

Specialty Workers’ Compensation Division

Named Insured: Web Address:

Contact Names and Phone Numbers

Inspections: / Phone:
Premium Audit: / Phone:
Claims: / Phone:

Prior Payroll and Premium Information

Total Annual Payroll
/
Total Annual Premium
Current Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:

Employee Profile & Hiring Practices

Years in business? Hrs of Operation? # of shifts?
# of employees? Full-time Part-time? Seasonal? Volunteers?
Any day laborers or leased employees? Yes No Iyeprovide details / Provide details:
% of non-union employees? % of union employees? What union?
# of W-2’s issued? Last year? Prior Year? Avg ee tenure?
How are employees paid? Hourly? Piece Rate? Commission? Salary? Other?
Starting wage for employees in governing class? $/hr Avg wage for employees in governing class? $/hr
Written application / Yes No / Post offer drug testing? / Yes No
Reference checks? / Yes No / Post accident drug testing? / Yes No
Pre-hire MVR checks? / Yes No / After hire, how often are MVR’s checked? /
Post offer physicals? / Yes No / Formal job descriptions on file? / Yes No
Orthopedic back testing? / Yes No / Is job specific training provided? / Yes No
Audio hearing testing? / Yes No / Are pre-existing injuries documented? / Yes No
New hire safety orientation? / Yes No / Is the orientation documented? / Yes No
Are Subcontractors used? / Yes No / If yes, are Certificates of Insurance on file? / Yes No
Independent Contractors used? / Yes No / If yes, how are independents paid? / 1099? Other
For what purpose are subcontractors or independents used?
Operations and Employee Benefits
Is Group Medical available to all F.T. employees? Yes No / Is there a driving/delivery exposure? Yes No
Waiting period? % paid by employer ? % / If yes, what is frequency? Daily Weekly Other
% of workforce actually paticipating in medical plan? % / Radius of travel: < 50 miles 50-100 100+
Paid Sick Leave provided for all employees? Yes No / Do multiple workers ride in the same vehicle? Yes No
Paid Vacation provided for all employees? Yes No / If yes, how many? How often?
Retirement/401K plan for all employees? Yes No / Are vehicles company owned? Yes No
Do any employees work from home? Yes No / If yes, are vehicles taken home at night? Yes No
If yes, how many & what do they do? # / # of employees who use personal car for business?
Duties: / Is there a vehicle/fleet maintenance program? Yes No
Any international travel? Yes No / If yes, who does the servicing?
If yes, how many ee’s travel? Where to? How often? Trip length? /
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Safety Program and Procedures

Is an active, written safety program in place? Yes No / Are accidents investigated & documented? Yes No
Do you have a safety manager? Yes No / Name & Title?
Is the safety manager a full-time or an additional duty for someone? / Full Time Position An additional duty
Cal/OSHA visits or citations in the last year? Yes No / If yes, provide details
Are safety meetings conducted regularly? Yes No / How Often? Daily Weekly Monthly Quarterly
Is an active safety incentive program in place? Yes No / Describe the incentive
Do employees receive safety training? Yes No / If yes, is the training Formal/documented Informal
Is forklift training provided? N/A Yes No / If yes, is annual certification required? Yes No
Does safety affect supervisors’ job reviews? Yes No / Explain how
Any manual lifiting exposures? Yes No / If yes, is the lifiting < 25 lbs. 25-40 lbs 40+ lbs
Any mechanical lifting devices used? Yes No / If yes, what types?
Is all machinery properly guarded? Yes No / Condition of most equipment New Good Average
Written lock out / tag out procedures in place Yes No / Any CNC machines? Yes No What % are CNC
Is personal protective equipment provided? Yes No / What types of PPE?
Hearing conservation program in place? N/A Yes No / Does it include pre-hire & annual audio testing? Yes No
Respiratory program in place? N/A Yes No / Does it include annual pulmonary testing? Yes No
Mat’l Safety Data Sheets kept for all chemicals? Yes No / Primary chemicals used?
What is the max height at which employees work? / Equipment used? Ladder Scaffolding Scissor Lifts
If scaffolding is used, do you build your own? Yes No / Age of building occupied? # of stories?
Type of construction? Sprinklered? Yes No / Is building sprinklered? Yes No
Are building evacuation drills conducted? Yes No / If yes, how often?

Claims Management Practices

Does a specific medical clinic treat injured ee’s? Yes No / Name/Addess
If the clinic isn’t in our network, will you change? Yes No / Has the clinic visited your facility? Yes No
Are written job descriptions provided to the clinic? Yes No / Is CPR training provided? Yes No # certified?
Are there set procedures for reporting claims? Yes No / Describe them
Average lag time in reporting claims? / Do you have a modified duty program? Yes No
Does the RTW program offer salary continuation? Yes No / What % of the time can you really provide modified duty? %
Retail/Wholesale
Type of merchandise? / %Wholesale %Retail Warehousing Yes No
Any repackaging operations? Yes No Explain
Any assembly exposure? Yes No Explain
Any distribution exposure? Yes No Do you use: Your own employees? Common Carrier? Owner/operators?
Machine Shops
Types of machines (must equal 100%) Heavy Mid Light
Any punch or brake presses? Yes No % of equipment that is Computer Network controlled machinery?
Age of machinery: < 2 yrs 2-5 yrs 5-10 yrs 10+ years
Machine guarding: Point of operation Drive mechanism Accessible moving parts

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Contractors
Indicate % of work conducted in each of the following operations: (Each line must total 100%)
New Construction: % / Remodeling: % / Service/Repair: %
Commercial: % / Apts/condos/tract homes? % / Custom Homes %
Interior: % / Exterior? % If exterior work is done, what is the max height?
Indicate % of work conducted in each of the following operations (must total 100%). Indicate N/A if no work is performed in that area
Blasting / Demolition / Light Pole Work / Wrecking / Street/Road Work
Grading / Gas Mains / Water Mains / Sewer / Freeway/Highway Work
Asbestos / Crane Work / Concrete Tilt-up / Concrete Walls / Concrete Flat Work
Roofing / Exterior Framing / Scaffold Set-Up / Plastering / Supervision Only
Excavation / Drilling / Tunneling / Bridge Work / Structural Steel
Paving / Dry Wall / Spray Painting / Electrical / Other
Any work below grade? Yes No If yes, max depth in feet? % of total work
Any work done at heights? Yes No If yes, max height in feet? % of total work
Any use of cranes, booms or similar heavy construction equipment? Yes No
Any work involving asbestos, hazardous product abatement, chemical/petroleum products, USL&H, underground tank or pipe replacement
Yes No If yes, please explain:
Any confined spaces exposure? Yes No If yes, provide details below & a copy of safety procedures and employee training
% of work sub-contracted out? What type?
Are Certificates of insurance obtained from subs? Yes No Does the insured directly supervise the subs? Yes No
Average # of certificates collected annually Average # of Waivers of Subrogation needed annually
Landscaping
Any tree trimming performed off the ground? Yes No / Any tree or boulder removal performed? Yes No
Any highway or median work performed? Yes No / Any use of tractors, loaders or similar eqpt? Yes No
Any use of pesticides or fertilizers? Yes No / If yes, is it applied by Employee? Outside Vendor?
Any use of chippers, mulchers, cherry pickers, booms or other similar equipment? Yes No
If yes, please explain :
Any debris removal or land clearing activities? Yes No
If yes, please explain :
Supplemental Information
In the past 3 years, have you made any changes in operations or discontinued any operations? Yes No
If yes, please explain :
In the past 3 years have you made any changes/improvements in your safety programs or procedures? Yes No
If yes, please explain :
In the past 3 years, have you automated any tasks that were previously performed manually or bought any equipment that has reduced the risk of injury to your employees? Yes No
If yes, please explain :

Prepared By Title Date

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