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GENERAL SUPPLEMENTAL APPLICATIONInsured:Address:Website:Effective Date:Completed by:Do you control this account?Date:YesNoOPERATIONS/EXPOSURESDetailed description of the operation:1. Number of employees is:IncreasingDecreasing2. # of W-2’s issued last year:Future layoffs foreseen?3. Number of employees: Full time:4. Employees are paid?Average hourly wage:HourlyStablePart-time:Piece Rate5. Do any employees work from home?If yes, how many?What are their duties?6. Average length of employment:Ratio of supervisors to employees:Average supervisor years of experience:YesSeasonal:CommissionNoVolunteers:Flat SalaryOther:NoAverage number of years of experience:Average supervisor length of employment:7. Hours of operation:24 hours a dayDaily from 11:00AMPM to 11:00AMPMNumber of shifts:Any weekend, night-shift, or graveyard shifts?YesNoIf yes, please provide details:Any day-laborers or temporary/employee leasing used?YesIf yes, please provide details:8. Any off-premises operations?YesPlease describe these operations:YesNoNo If yes, what percentage9. Are you currently participating in a MPN (Medical Provider Network)?If yes above, please provide the name of current MPN:%YesNoInsurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111
GENERAL SUPPLEMENTAL APPLICATION10. Has the ownership of the applicable entity changed within the past 5 years?If yes above, please provide details:11. Does the insured belong to any trade associations?If yes please list them:12. Any group transportation of employees?If yes, how are employees transported?Number of employees in a vehicle:YesYesNoNoYesNoCarTruckVanNumber of vehicles:BusOther:Frequency:SAFETY PROGRAM1. Does the insured have a full-time Safety Director on staff (no additional job duties)?If yes, how long has there been a designated safety person?Name:Title:2. Formal safety incentive program?YesIf yes, what type of incentive(s)?If yes, does it encompass all employees?YesNoNo4. Do you have an early return to work program?YesNo If yes, is it:If yes, does it include salary continuation?YesNoYesNo6. Are MVR’s checked Pre-hire and Annually?Pre-hireFormalInformalPost AccidentYes7. Are owners active in daily operations?YesIf yes, are they excluded from coverage?Yes8. Are safety meetings conducted?YesIf yes, are they:Formal/documentedNoNo3. Do you have a accident investigation program?YesNoIf yes, do you have a formal written accident report?Yes5. Formal Drug Testing?YesNoN/A - No driving exposuresNoNoNoInformal9. Is CPR training provided?YesNoIf yes, number of employees certified:Insurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111
GENERAL SUPPLEMENTAL APPLICATION10. Any material handling exposures?YesNoIf yes, please explain:How much is lifted by hand: 25 lbs.25-4040 List any mechanical lifting devices used:Forklifts used?YesNoIf yes, is forklift training provided?YesNoIs there annual Certification for forklift drivers?YesNoNumber of Forklift Drivers:Number of forklifts:11. Has loss control services been performed in the last year?YesHas Cal/OSHA visited or cited your business in the last year?YesIf yes to either of the above, please provide explanation:12. Is PPE mandatory?YesNoPersonal protection equipment (PPE) provided?YesWhat PPE is used?Back BeltsFace GuardGogglesGlovesMasksRespiratorsHearing protection devicesOther:No13. What is used?LadderScaffoldingScissor liftsIf scaffolding is used, does the insured construct their own?Is there strict enforcement of utilization?YesNoWhat is the maximum height at which you will work?14. The building/premises:OwnedLeasedWhat is the condition of the premises?ExcellentNoNoN/AN/AYesVery goodNoAverage15. Please answer the following questions by marking the applicable box:Is a respiratory program in place?YesNoN/AIs all machinery/equipment properly guarded?YesNoN/AAre all equipment operators trained/certified?YesNoN/AWhat is the condition of equipment?NewGoodAverageN/AMaterial Safety Data Sheets available for all chemicals and products used?YesWritten Lock out/tag out/block out procedures in place?YesNoN/ANoN/AInsurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111
GENERAL SUPPLEMENTAL APPLICATIONPREMIUM/PAYROLLPlease use estimated premium and payroll for the current policy and audited premium and payroll for allprior periods. Please provide payroll and premium going back at least 4 full years.Current policy period1st Prior policy period2nd Prior policy period3rd Prior policy periodPremium Payroll Please explain reason(s) for breaks in coverage or policies greater than or less than a full year:BENEFITS1. Group medical provided?YesIf yes, name of Healthcare Provider:% of employees enrolled:%If yes, who is eligible:FTPT2. Paid Sick Leave?Paid Vacation?YesYesNo% paid by employer:%SeasonalManagement/Supervisors only?NoNo3. What is the average weekly wage of the employees in the governing class? 4. Retirement/Pension plan?YesIf yes, does employer contribute?NoYesNo5. Do you use a specific medical provider to treat injured employees?YesNoHIRING PRACTICES1. Are personnel files documented for pre-existing injuries?2. Employee Orientation Program?YesVerbal and DocumentedYesNoVerbal onlyNoneInsurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111
GENERAL SUPPLEMENTAL APPLICATION3. Please answer the following questions by marking the applicable boxWritten Application?YesNoIs a background checking service used?Reference Checks?YesNoFormal job descriptions on file?Orthopedic back testing?YesNoIs job specific training provided?Audio hearing tests?YesNoPathogenic test (i.e. lead)?YesYesYesYesDRIVING EXPOSURES1. Does the insured have employees who perform pick-up or delivery?YesNoIf yes, how frequently:DailyWeekOtherAre motorcycles used for any driving pick-up or delivery operations?YesNoDoes the insured participate in the CHP Pull Program?YesNoTravel Radius:50 Miles or Less51 – 100 MilesGreater than 100 Miles# of Vehicles:# of drivers:2. Vehicle/Fleet maintenance program?YesNoIf yes, who performs the service?Outside Vendor3. Vehicle Inspection program?4. Are company vehicles owned?YesYesIn-house employeesNoNo If yes, are vehicles taken home?5. Has a driver acceptability standard been established?Yes6. Do employees use company vehicles for personal business?Do employees use personal vehicles for errands or deliveries?7. Is a PUC/DMV filing program required?PUCDMVIf a PUC/DMV filing is required what is the number?YesNoNoYesYesNoNoN/ATRAVEL EXPOSURES1. Any out of state, international or overnight (within state) travel?YesIf yes, please provide details and purpose:Who will travel?# of employees who travel:Mode of e Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111NoNoNoNo
GENERAL SUPPLEMENTAL APPLICATIONCATASTROPHIC EXPOSURE1. Does the insured work within 2 miles of the following: Government or military base, financial institutions,sports stadiums, arenas, theme parks, major bridges, tunnels, dams, utilities/power plants, transportationhubs, railroads, airports, shipping, historic/symbolic buildings, monuments or parks:YesNoIf yes, please explain:2. Do they have employees in a 4 story building or greater:If yes above, structure of buildings is:Tilt up ConcreteYesNoMasonrySteelWood Frame/StuccoCLAIMSFor claims over 25,000 please advise us of the following on a separate sheet:Was it an accepted claim?Is the employee still working for the insured?How did it occur?What was the injury?What corrective action has the insured taken to prevent reoccurrences?AGRICULTURE/FARMING1. Insureds operations (check all that apply):Farm Labor ContractorFLC #:Field CropsCrops/Acres:Truck farmCrops/Acres:OrchardCrops/Acres:Vineyard% of insured’s acreage devoted to growing table grapes:LivestockTypes of livestock:DairyDude RanchOther:If Strawberry farm, are berries grown in raised beds (2 or more feet)?Does insured grow mushrooms?YesNo2. Do any family members work in operation?Yes3. Harvesting process:MechanizedManualIf manual, are employees paid by piece (piecework)?4. Are pruning operations performed by employees?YesNoNoYesYesNoNoBy othersInsurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111
GENERAL SUPPLEMENTAL APPLICATION5. Any crops/orchards located on hillsides or slopes?YesNo6. Does insured use an outside vendor for chemical/pesticide application?Does insured perform any aerial crop dusting operations?YesNoYesNo7. Does the insured perform any packing operations of fruits/vegetables in the field?YesNoDoes the insured perform any packing operations of fruits/vegetables away from field?YesNo8. Does the insured perform delivery?YesNoIf yes, number of delivery vehicles:Delivery distance:Does insured employees perform tarping or climb on trucks/trailers:YesNo9. Are operations seasonal?YesNoIf yes, season begins:ends:# of seasonal employees hired:% of insured’s seasonal employees that return each year:%NoneIs housing provided?YesNoIf yes, # of employees housed?10. Does the insured provide group transportation (4 or more people in one vehicle)?If yes, how many employees at one time in one vehicle?One parcel to another parcel, within farmOne farm to another farm, less than 10 milesOne farm to another farm, more than 10 miles. Average distance:milesYesNo11. Does the insured own or operate any ATV’s?YesNoIf yes, what type?3 Wheeler4 WheelerGatorSide by SideOtherHow many ATV’s, including employee owned, are used?12. Any confined spaces exposures?YesNoIf yes, please provide details (use separate page if needed):13. Is there an extreme temperature program that meets Cal OSHA requirements?YesNoAUTOMOTIVE SERVICES1. Does the insured have towing, roadside services or mobile operations?If yes, any contract towing?YesNoIf yes, is there 24 hour exposure?YesNoYesNoInsurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111
GENERAL SUPPLEMENTAL APPLICATION2. Is there a Mini-market on premises?YesNoIf yes, any sales of alcoholic beverages?YesNo3. Please answer the following questions by marking the applicable box:Open 24 hours?YesNoAny fueling operations?Security cameras used?YesNoAny transportation of customers?Is cashier’s booth bullet proof?YesNoAny fueling operations?4. Access to Freeway?0-1 mile1-2 milesYesYesYesNoNoNo2 miles5. How many employees are ASE trained and certified?6. Does the insured have employees participate in/on racing teams or racing events?YesNoCONTRACTORSPlease attach a project list for the last 12 months and a bid list for the next 12 months1. Has the insured been in business with Workers’ Comp Insurance for 3 years or more?YesNo2. Does the insured have a current and active Contractor’s License?YesNoContractor’s license number:Years of experience in trade:Estimated # of jobs per year:3. Indicate % of work conducted in each of the following operations (must equal 100% for each line):New Construction%Remodeling/Service/Repair% 100%Commercial%Residential% 100%Interior%Exterior% 100%If exterior work is done, what is the maximum height exposure?4. Does the insured hire “Day Laborers”?5. Is the insured a Union Contractor?YesYesNoNo6. Any use of cranes, booms or similar heavy construction equipment?7. Any work below grade?YesNoMax Depth in feet:YesNoPercent of total work:8. Any confined spaces exposures?YesNoIf yes, please provide details (use separate page if needed):Insurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111%
GENERAL SUPPLEMENTAL APPLICATION9. Any work involving asbestos, hazardous product abatement, chemical/petroleum products, USL&H,underground tank or pipe replacement:YesNoIf yes, please explain:10. Does this risk conduct work for the government or city municipalities?YesNo11. Is the applicant involved in “Wrap Up” or “OCIP” projects?YesNoIf yes, please provide percentage of total payroll dedicated to these projects:%Advise details on how applicant determines employee split between these projects and other contracts orprojects (not Involving “wrap up” or “OCIP”):12. Indicate % of work conducted in each of the following operations (if any):Asbestos% Blasting% Bridge WorkCrane Work% Demolition% DrillingExcavation% Exterior Framing% Gas MainsHighway Work% Light Pole Work% Multi-Story BuildingsScaffold set-up% Sewer% Spray paintingStructural Steel% Supervisory only% Tunneling%%%%%%Concrete Tilt-upDock/Sea WallsGradingRoofingStreet/road workWrecking13. Does the insured have an extreme temperature program meeting Cal OSHA requirements?YesJANITORIAL CONTRACTORS1. Which one of the following best describes the insured’s operations (Please select only one option):Commercial Office Cleaning – No Waxing/Polishing of Floors or WallsCommercial Office Cleaning – Including Waxing/Polishing of Floors or WallsResidential cleaningPool cleaningSweeping of Parking LotsOther:2. Does the insured perform any of the following operations:Exterior Window CleaningCleaning of health care or industrial facilitiesCarpet CleaningCrime scene or Bio-Hazard clean-upMobile Power/Pressure Washing servicesGraffiti removalWater or fire damage restorationChimney cleaning from the roofPest ControlAluminum Nitrate handlingFire Extinguisher refilling, service or repairInsurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111%%%%%%No
GENERAL SUPPLEMENTAL APPLICATION3. Do they have on-site cleaning equipment and supplies?YesNo4. What is the number of building the majority of your crew(s) service per shift:1 Building2-3 Buildings3 or more buildings5. Does the insured have Independent Contractors or 1099 Employees?Yes6. Employees supervised?YesNoDo employees work in pairs or more?DirectIf yes, supervision is:NoYes7. Any group transportation of employees?YesNoRovingNoLANDSCAPING1. Does the insured perform any of the following operations:Weed abatementAbove ground level tree trimmingMore than incidental excavation workClearing of land and/or debrisHabitat restorationSet-up of holiday decorationsErosion controlRemoval of parasitic vines like mistletoeTree planting greater than 15 gallonsTree removalSprinkler installationAny work that required excavation or trenching below 6’Work along non-residential medians or major roads/highways2. Does the insured hire “Day Laborers”?YesNo3. Percentage of operations that apply to insured:Mow and Bow:%Landscape Design:%Hydro Mulch:%4. Do the insured’s operations include snow removal?YesLess than 10%More than 10%If yes, does the insured perform any snow removal from rooftops?YesNo5. Does the insured install artificial turf?YesNo6. What percentage of the risk's operations are:Residential%New%Commercial%New%7. Does the insured do hardscape work?If yes, % of the following operations:Concrete or Masonry Work%Swimming pools/spas%Fences%YesRemodelRemodel%%NoRetaining wallsWaterfalls/pondsDecks%%%Insurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111No
GENERAL SUPPLEMENTAL APPLICATION8. Any use of chippers, mulchers, cherry pickers, booms or other similar equipment?If yes above, please explain:YesNo9. What % of operations involves landscape work on green buildings (rooftops, sides of buildings)?%MANUFACTURING1. Provide a brief description of the product manufactured:2. What is the weight of the insured’s finished product (Please select only one option)?Less than 5 lbs.6 lbs. to 25 lbs.26 lbs. to 50 lbs.Greater than 50 lbs.3. Is 51% or more of the insured’s product produced via a Computer Pneumatic Controlled machine or aCAD/CAM machine?YesNo4. Does the insured have assembly operations?If yes, does the insured have job rotation?YesNoYesNo5. What types and percentage of raw materials does the insured dmium%Lead%Nickel%Chromium%Other:%6. How many of each type of machine shown below are used?CNC#Planer#MillingStamping#Drilling#Power PressesCutters#Saws#WeldingDie Casting#Press Brakes #Jig BorerPunch Press#Other (type and number):6. Who is responsible for maintaining machinery?7. Does the insured do any installation?If yes, please explain:Yes8. Is there any off premises work?YesIf yes, what are these operations & rindersSandblastingLathesOther:NoNoif Yes, what percentage:%Insurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111####
GENERAL SUPPLEMENTAL APPLICATION9. Any interchange of labor?If yes, please explain:10. Age of machinery:Yes 2 yearsNo2-5 years5-10 years10 years11. Accessible moving parts guarded on machinery/equipment?12. Is building properly ventilated?YesIs proper dust collection system in place?NoYesYesNoNoHOTEL/MOTEL1. Which of the following best describes the risk's operations?HotelRating: No RatingRating: No RatingHotel/CasinoMotelRating: No RatingBed & BreakfastRating: No RatingTimeshareBrand Name:Fraternity/Sorority HouseBoarding House2. Does the insured rent their rooms by the hour?YesDude RanchYesBrothelNo3. Does the insured use sub-contractors for their major repairs?4. Does the insured provide shuttle service?HostelYesNoNo5. Do they have the ability to store their cleaning equipment on each floor?If yes, do they have access to an elevator?YesNoYesNoRESTAURANTS1. What type of restaurant best describes the insured’s operations? (Check all that apply)Fine Dining (Entrée Price 20 or )Casual Dining/Family StyleDiner (IHOP/Denny’s, etc.)Banquet HallCafeteria/BuffetHotel/Resort RestaurantFast FoodPizza DeliveryMobile Catering TruckTavern/Sports BarGentleman’s ClubNight Club2. Does the insured do any off-site catering (delivery and set-up of food)?3. Does the insured have entertainment?YesYesNoNoInsurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111
GENERAL SUPPLEMENTAL APPLICATION4. Does the insured have security guards or bouncers?Yes5. Are any of the insured’s locations open after 11 pm?6. Does the insured require non-slip shoes?If yes, is this a “Shoes for Crews” program?7. What is the percentage of liquor sales?YesYesYesNoNoNoNo%RETAIL/WHOLESALE1. Type of Merchandise?2. Gross Receipts: Wholesale% Retail3. Does the insured have repackaging or assembly operations?If yes, please explain operations:%Warehousing?YesYesNoInsurance Company of the West Explorer Insurance Company VerTerra Insurance Companywww.icwgroup.com 800.877.1111No
Insurance Company of the West Explorer Insurance Company VerTerra Insurance Company www.icwgroup.com 800.877.1111 icw-group-supplemental-application-general
