1. Business Information Company Name: * DBA: * Yes No If YES: FIN/EIN: * Number of Locations: * Select: 1 2 3 4 5 5+ Years in Business: * Select: 1 2 3 4 5 6 7 8 9 10 10+ Physical Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Business Phone: * (###) ### #### 2. Personal Information Primary Contact: * First Name Last Name Primary Contact Phone: * (###) ### #### Primary Contact Role: * Select: Owner President Manager Accountant Partner Billing Spouse CEO COO CFO Secondary Contact: First Name Last Name Secondary Contact Phone: (###) ### #### Secondary Contact Role: Select: Owner President Manager Accountant Partner Billing Spouse CEO COO CFO 3. Employees & Payroll Number of Full-time Employees: * Number of Part-time Employees: * Do you use and seasonal or temporary workers? * Yes No Estimated Annual Payroll: * Estimated Annual Revenue: * Services Provided: * Days of Operation: * (Check ALL that apply) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Holidays? (Check ALL that apply) None Government Holidays Major Holidays Number of Shifts: Select: 1 2 3 4 Do you have a formal or informal training program for new employees? * Yes No Regular training sessions held? Yes No If YES, how many times per year? Select: Monthly Quarterly Bi Yearly Yearly Do you have a safety program? * Yes No (If YES, Please describe your safety program.) Are employees required to wear safety equipment? (If YES, select ALL that apply) Goggles Work boots Non-slip shoes Gloves Respirators Helmets Reflective vests Other: 4. Drug-Free Policy Do you have a drug-free workplace policy? * Yes No *At hire or fandom testing? At hire Random Both 5. Return to Work Do you have a policy for employees to report workplace injuries? * Yes No Do you have a return to work program? * Yes No *If YES, does it include accommodating work schedules and functions? Yes No 6. Driving Are there and driving exposures? * Yes No *If YES, how many employees drive? What type of vehicles? Deliveries / Other? Yes No Radius of drive one way? (Please Select) 0 - 50 Miles 50 - 100 Miles 100 - 200 Miles 200 - 300 Miles 300 - 500 Miles 500+ Miles Any money carried by drivers? Yes No Scheduled or random routes? Scheduled Random Both Minimum age of drivers? Do you check MVR's? Yes No 7. Lifting Maximum weight lifted by employees? (Please Select) 10lbs 20lbs 30lbs 40lbs 50lbs 50+lbs Type of item(s) in excess of 20lbs? Are employees required to wear back braces or supports when standing for long periods of time or lifting? Yes No Do employees use forklifts, pallet jacks or any other type of heavy equipment? Forklifts Pallet Jacks None Other: Does your training include use of these items? Yes No Not Applicable 8. Machinery & Hand Tools Any machinery opperated by employees? * Yes No Any maintenance done by employees? Yes No *If YES, what type? Machinery safety features: (Select ALL that apply) Automatic Shut-offs Light-curtains Guarded Pinch Points Guarded Cutting Points Two Handed Activation Foot Pedals Other: Any cutting done by hand or machine? * Hand Machine Both None *If YES, what type of products? Conveyor belts? Yes No Packing, taping or cutting products or boxes? Yes No *If YES, are cutters guarded? Yes, Cutters are guarded. No, Cutters are not guarded. Any welding or soldering? Welding Soldering Welding & Soldering None 9. Heights & Depths Any work done on ladders or scaffolding? * Ladders Scaffolding Ladders & Scaffolding None Any work done over 6 feet? * Yes No *If YES, what is the maximum height? Any fall arrest system of protection used? Yes No Not Applicable *If YES, please explain: Any work done below grade? * Yes No *If YES, maximum depth? Any underground excavation? * Yes No *If YES, are employees using manual or mechanical tools to dig? 10. Other Exposures Any exposures to: (Select ALL that apply) Chemicals Cleaning agents Oils Pesticides Fertalizers Asbestos Metal cuttings High dust concentrations Raw foods Common allergens *If YES, please explain: 11. Losses Have you had and workers' compensation injuries in the past 5 years? * Yes No *If YES, Please list the number and a description of claims in excess of $5000.00 12. Sign & Submit Additional Comments: Completed By: * By entering your name and clicking “Submit” you authorize East Coast Insurance Services, LLC and its affiliates to obtain insurance quotes on the behalf of your business of organization. First Name Last Name Title: * Today's Date: * MM DD YYYY Thank you, someone will be in contact with you within the next business day. Workers’ Compensation Application
