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?
