California Workers Compensation

PACIFIC GLOBAL
Insurance Brokers
California Insurance License #OC15050

Workers' Compensation Program

Application Form

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Note: We primarily serve larger accounts.

Kindly proceed with this application process if your business

generates at least $10,000 in workers' compensation annual insurance premium.

Consider Pacific Global for your Benefits Package

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Instructions: If you are interested in receiving a competitive quote on your workers compensation insurance, please fill out the following form as completely as possible. When finished, click on the submit button at the bottom of the page. Thank You!

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Business Information

Name/DBA:
Contact Name:
Phone Number:
Fax Number:
Business Address:
City:
State:
Zip:
E-mail:
Web Site URL:

Number of years in business:
Business Structure (Inc./ Partnership/Individual / LLC):

Business Description

Federal Employer ID Number:
What State(s):

Description of Business Operations:

Business Locations
Location# 1

Name:
Address:
Suite/Unit:
City:
County:
State:
Zip:

Other Locations

Name:
Address:
Suite/Unit:
City:
County:
State:
Zip:

Individuals Excluded from Coverage
(must be corporate officers who also own stock)
#1

Employee Name:
Title:
Ownership %
Duties: (i.e. Active Management)

Employee Name:
Title:
Ownership %
Duties: (i.e. Active Management)

#Other

Employee Name:
Title:
Ownership %
Duties: (i.e. Active Management)

Prior Carrier Information

Policy Expiration Date
Carrier:
Policy #:
Annual Premium:
Number of Claims:
Amount Paid:
Amount of Open Reserves

General Information
Answer each of the following questions either "yes" or "no". Explain all "yes" answers in the box provided below.

Yes	No	Does applicant own, operate or lease aircraft/watercraft?
Yes	No	Is applicant engaged in any other types of business?
Yes	No	Any part-time or seasonal employees?
Yes	No	Any prior coverage declined/canceled/non-renewed?
Yes	No	Any employees under 16 years of Age?
Yes	No	Any employees over 60 years of age?
Yes	No	Is a formal safety program in operation?
Yes	No	Are physicals required after offers of employment are made?
Yes	No	Any volunteer or donated labor?
Yes	No	Are employee health plans provided?
Yes	No	Are athletic teams sponsored?
EXPLANATION

Employee Benefits
Average number of employees excluding officers, partners, and sole solicitors:
Full time: Part time:
W-2's issued last year:
Average wage and total number of workers by class codes:

Company paid benefits
(check all that are applicable):

Health		Disability		Sick Leave
Vacation		Union		Other

Management
Number of years in business under current management?
Number of years experience of management in this line of business?
Is this business owner managed? YES: NO:
Designated industrial medical provider:

Employee Selection & Workplace Safety
Check all that are applicable

	Written employment application.
	Written orientation program.
	Written discipline procedure.
	Early return to work program.
	Safety incentive program.
	Pre-employment physical.
	Drug screening.
	Reference checks.
	Motor Vehicle Report checks.
	Use of personal protective equipment enforced.
	Exposures control.

Claims History
If there have been claims in any of the following categories, please indicate and explain in the comments box below.

Please provide your last three years loss history. This can be obtained by contacting your insurance carrier for those respective years.
Fax Documented Loss Runs to 818-475-1948.

Kindy answer Yes or No to the following:

Yes

No

Losses over $25,000.

Yes

No

Psychological stress.

Yes

No

Accidents involving multiple employees.

Yes

No

Harassment / Wrongful discharge

Yes

No

Attacks/Physical violence against employees.

Yes

No

Cumulative/Repetitive trauma.

Yes

No

Employer's liability.

EXPLANATIONS

Enter the Estimated Annual Payroll statistics
from which the new insurance policy premium will be developed.

Classification Code	Number of Employees	Estimated Annual Payroll

IMPORTANT NOTE: This workers compensation form is provided as a convenience to you. A good faith effort to obtain a competitive quote will be made on your behalf. Depending on the type of business, we may require more information and will contact you if necessary. Submission of this form DOES NOT guarantee that any binding of workers compensation coverage will be forthcoming from insurers we represent. In no way does submission of this form obligate anyone to any contract.

Thank you for your submission.

©2005 Pacific Global Insurance Brokers

Yes	No	Losses over $25,000.
Yes	No	Psychological stress.
Yes	No	Accidents involving multiple employees.
Yes	No	Harassment / Wrongful discharge
Yes	No	Attacks/Physical violence against employees.
Yes	No	Cumulative/Repetitive trauma.
Yes	No	Employer's liability.
EXPLANATIONS