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Mike Stromsoe 
Certified Work Comp Advisor 
Author, Speaker, Consultant
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*required fields

General Information About Your Company
 
*Company Contact Person
*Full Company Name
*Company FEIN (Fed. Employer ID#)
Street Address
Address (cont.)
City
State
Zip Code

Please list additional locations in "Comments" Box at end.
*Work Phone
Fax
*E-mail
Website

Current Work Comp Insurance
 
Check here if NEW venture or NO current coverage
Name of Carrier (not agent)
Full Policy number
Current annual premium $
Number of claims last 24 months
Any lapse in coverage last 24 months
Current Policy Expiration Date:
 

Your Company Operations
 
Entity: Corporation    Partnership    Sole Proprietor    Other
Other (please describe):
 
How long has this entity been in business? 
 
Does any officer, partner or family member have ownership interest in any other business?   Yes    No
Describe: 
 
List all Partners, Officers, Spouses or Members of your owned entity:
(list additional in comments section at the end)
  Name Date of Birth Title % of Ownership Include or Exclude
1.

%
2. %
3. %
 
Is any work performed or is there travel outside of CA?   Yes    No
Describe: 
 
Any piecework based compensation? Yes    No
Is any portion of the work subcontracted? Yes    No
Describe:
Are subs' required to provide proof of insurance and license numbers? Yes    No
Describe:
Any work performed on the customers' premises? Yes    No
Describe:
Are any products manufactured? Yes    No
Describe:
 
 

  Gross Annual Payroll                      Employee Information
 
Current year: $ # of Full Time:
1st prior year: $ # of Part Time:
2nd prior year: $ Seasonal/Temporary:
3rd prior year: $ Annual Employee Turnover Rate %
# of Employees in each crew: Are any employees union?

Yes  No

# of shifts worked: If yes, do they pull from the hall? Yes  No
# of employees on each shift: Do employees rotate job duties? Yes  No
# of Seasonal Employees: Are temporary employees used? Yes  No
# of Volunteers:  
       
 

Describe Your Employee Benefits
 
Is group medical coverage provided? Yes  No
Who is eligible?
% of employees covered by the group health plan: %
Is health plan paid by employer? Yes No
% paid by employer for employee? %
Waiting period for new hires?
Is there paid sick leave? Yes No
Is there paid vacation? Yes No
Retirement plan? Yes No
Name of group carrier:
   
 

Describe Your Hiring Practices
 
Is there a job description used in the hiring process? Yes No
Are pre-employment physicals required? Yes No
Are background checks done? Yes No
Are pre-employment reference checks made? Yes No
Is it a drug-free workplace? Yes No
Are pre-employment and post-accident drug testing done? Yes No
Is new employee training provided? Yes No
 
 

Machinery Used in Your Business
 
Type of machinery: (if none leave blank) Age of Machine
 
Are the employees certified to operate forklifts, if any?  Yes No
 
Any welding? Yes No Any painting? Yes No
Any heat treating? Yes No Any polishing? Yes No
Any plating? Yes No Are CNC machines used? Yes No
Please check if any of the following exotic metals are used in your business:
Aluminum Beryllium Copper
Titanium Nickel Magnesium
Brass Lead Other
 
 

Tell Us About Your Safety Programs
 
Is there a formal written safety program? Yes No
Is there a safety director? Yes No
Full time or Part time
Who is in charge of safety?
Are supervisors or foremen held accountable? Yes No
Is their pay affected? Yes No
Are all machines guarded? Yes No Is there a hazardous communication program? Yes No
Is there a written lock out/tag procedure? Yes No Are material safety data sheets available? Yes No
Is personal protective equipment provided? Yes No Is use of personal protective equipment enforced? Yes No
Please describe the type of personal protective equipment used:
 
 
Is there a first Aid facility available? Yes No  
Is there an early return to work program for employee injured on the job? Yes No  
Are light duty positions available? Yes No  
Are safety meetings conducted? Yes No  
  How often?
Is safety training provided? Yes No  
  How often?
Is there an accident investigation policy? Yes No
Who is in charge of accident investigation and what is their title?
Do you have a designated medical provider? Yes No
 
 

Your Business Driving Exposures
 
Number of Company Vehicles: Delivery provided?

Yes No

Number of Company Authorized Drivers: Driver training provided? Yes No
Radius of Travel (in miles) How often?
MVRs Checked? Yes No Participate in DMV Pull Program? Yes No
How often? Any driving out of state? Yes No
How often vehicles inspected? Any out of state driving?  
If yes, list all states below:
How often vehicles serviced?

 
 

Other On-The-Job Hazards
 
Maximum weight lifted by employees
 0to25lbs: % 26to50lbs: % 50lbs+: %
 
   

If yes, what & how often?
Is any installation done?

Yes No

Do they perform work in the air? Yes No
Do they use scaffolding? Yes No
Do they use aerial lifts? Yes No
Do they work with/around electrical lines? Yes No
Do they deliver any product or components? Yes No
Any work performed underground or above 15 feet? Yes No
 

Additional Comments or Information
 
Please include comments or additional information in the box below:
 

 


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