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Business Legal Name
DBA Name (Doing Business As)
Fed Tax ID/FEIN
Street Address
Zip Code
Years in Business
Owner’s Name
Phone
Email
Type of Business -- Select --Sole PropCorporationLLCNon-Profit
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Description of Operations
List States of Operation
Type of Work -- Select --FARM: NURSERY EMPLOYEES & DRIVERSFARM: GARDENING-MARKET OR TRUCK & DRIVERSORCHARDSSUGAR CANE PLANTATION & DRIVERBEE RAISINGBULB RAISINGDAIRY: FARMFARM FIELD CROPSLANDSCAPE GARDENINGFARM MACHINERY OPERATIONORCHARD GROVE OWNERS AND OPERATORSFOR REPORTING DISEASE EXPERIENCE IN CONNECTION WITH ABRASIVE OR SAND BLASTING - SUBJECT TO EXPERIENCE RATINGFOR REPORTING DISEASE EXPERIENCE IN CONNECTION WITH INCIDENTAL FOUNDRIES - STEEL - SUBJECT TO EXPERIENCE RATINGFOR REPORTING DISEASE EXPERIENCE IN CONNECTION WITH INCIDENTAL FOUNDRIES - NON-FERROUS METALS - SUB TO EXP RATINGFOR REPORTING DISEASE EXPERIENCE IN CONNECTION WITH INCIDENTAL FOUNDRIES - IRON - SUBJECT TO EXPERIENCE RATINGVINEYARDS OR BERRY FARMSFARM: CATTLE OR LIVERSTOCK RAISINGTREE PRUNING, SPRAYING, REPAIRING, TRIMMING ORFISH HATCHERYLAWN OR SHRUB SPRAYINGANIMAL RAISINGBERRY FARM AND DRIVERSDITCH CLEANING - IRRIGATIONCOTTON GIN OPERATIONNON-RATED CATASTROPHE LOADING FOR 4771DOMESTIC WORKERS ? RESIDENCES ? PART TIMEDOMESTIC WORKERS ? RESIDENCES ? FULL TIMERESIDENTIAL CLEANING SERVICE BY CONTRACTOR-INSIDECOAL MINING - SURFACECAVE EXCAVATION - FOR EXHIBITGOLD MINING - BY HYDRAULIC PROCESSPHOSPHATE MINING & DRIVERSOIL OR GAS LEASE OPERATIONS - NATURAL GASCLEANING OLD OIL/GAS WELLSLEAD MFG.ALUMINUM SMELTINGGRAPHITE MFG. - NOT ARTIFICIALASPHALT WORKSALCOHOL MFG. - NOT BEVERAGETURPENTINE OR RESIN MFG. & DRIVERSFELDSPAR MININGLIME MFG.QUARRIESLIME MANUFACTURINGINSULATING MATERIAL MFG. - MINERALCEMENT MFG.STONE CRUSHINGABRASIVES OR ABRASIVES PRODUCTS MFG.ABRASIVES OR ABRASIVES PRODUCTS MFG.ABRASIVE WHEEL MFG.GRINDSTONE MFG. - NO QUARRYINGMICA GOODS MFG.ABRASIVE PAPER/CLOTH PREPARATIONWIRE DRAWING/CABLE MFG.DIE CASTING MFG.BAKERIESFEED MFG.BREAKFAST FOOD MFG.MOLASSES OR SYRUP REFININGDAIRY PRODUCTS MFG.CANDY OR CONFECTIONERY PRODUCTS MFG.CONDENSED MILK MANUFACTURINGBEVERAGE BOTTLER-SOFT DRINKS-NOT CARB.-IN PLSTC./CBUTCHERINGPACKING HOUSEMEAT PRODUCTS MFG.FRUIT PACKINGFOOD PRODUCTS MFG. - NOT DRY - IN GLASS CONTAINERSCANNERIESDEHYDRATING OF SOUPS OR VEGETABLESCLAM DIGGINGCITRUS PRODUCTS PROCESSINGBEER, ALE OR MALT LIQUOR MFG. - IN BOTTLESALCOHOL MFG. - GRAINLIQUOR MFG.BEVERAGE BOTTLER-SOFT DRINKS-CARB.-IN GLASS BTLS.CIGARETTE MFG.TOBACCO REHANDLING OR WAREHOUSINGCOTTON BATTING MFG.CARPET OR RUG MANUFACTURINGFIBER MANUFACTURING - NOCFELTING MFG.FIBER MANUFACTURING - NOCACETATE TEXTILE FIBER MANUFACTURINGCLOTHING MANUFACTURINGCLOTHING MANUFACTURINGBRAID OR FRINGE MFG.EMBROIDERY MFG.CARPET OR RUG MFG.SILKSCREEN PROCESS - CLOTH PRINTINGTEXTILE BLEACHING, DYEING, PRINTING OR SILK SCREENCLOTH PRINTINGCAP MFG. - CLOTHDRESSMAKING OR TAILORINGARTIFICIAL TREES MFG.MATTRESS OR BOX SPRING MFG.CARPET, RUG OR UPHOLSTERY CLEANING-ON CUST.PREMISECLEANING OR DYEINGLAUNDRY RENTAL SERVICELAUNDRIES AND DRY CLEANING STOREFUR DRESSING OR DYEINGFURS OR PELT PROCESSINGGASKET OR WASHER MFG. - NOT METALSHOE OR BOOT MFG.BASEBALL GLOVE MFG.BAG MANUFACTURING - LUGGAGEFOOTBALL OR BASKETBALL MFG.LOGGING OR LUMBERING & DRIVERSSAWMILLPLYWOOD, VENEER OR VENEER PRODUCTS MFG. NOCEXCELSIOR MFG.FURNITURE MFG. OR ASSEMBLING - WOODBOX OR BOX SHOOK MFG.AIRPLANE PROPELLER MFG. - WOODMOBILE OR TRAILER HOME MFG. & DRIVERSHOME SETUP, HOOKUP, OR INSTALLATION AT SITEBUILDING MFG. - PORTABLE - WOODBRUSH OR BROOM MFG.BRUSH OR BROOM MFG.AUTOMOBILE WHEEL MFG. - WOODCABINET WORKS - NO POWER MACHINERYFURNITURE MANUFACTURING-WOOD-NOCBARREL MFG. - INCLUDING VENEER MFG.BARREL MFG. - INCLUDING VENEER MFG.MUSICAL INSTRUMENT MFG.POLE/POST/TIE YARD/DRIVERIRON OR STEEL: MFG. - STEEL MAKINGIRON OR STEEL ROLLING MILL - BARS ONLYPIPE OR TUBE MFG. - NON-FERROUSLEAD WORKSPIPE OR TUBE MFG. - IRON/STEELBRIDGE SECTIONS - HIGHWAY - PREFABRICATEDIRON OR STEELIRON OR STEEL: FABRICATION: IRON WORKS-SHOP-DECORAELEVATOR MFG.NEON SIGN MFG.APPLIANCES AND ACCESSORIES MFG.-COMMERCIAL-NOT GASFOUNDRIES NOCCAR WHEEL MFG. - RAILROADALUMINUM FOUNDRYANCHOR MFG.BLACKSMITHMOLDS MFG. - METAL MOLDS FOR WHITE METAL CASTINGSHAND TOOLS MFG.FILE MFG.NEEDLE MFG.CUTLERY (NOT POWERED) AND FLATWARE MFG.AGRICULTURAL TOOL MFG. - HANDBOTTLE CAP AND CROWN MFG. - METALBOLT, NUT, RIVET, SCREW OR WASHER MFG.AUTOMATIC SCREW MACHINEAUTO WINDOW AND TRIM MOLDING MFG.APPLIANCES AND ACCESSORIES MFG.-COMMERCIAL-GASFOUNDRIES NOCELECTRICAL APARATUS MFG. NOCCHANDELIER MFG.PLUMBERS' SUPPLIES MFG.CAN MFG.AUTOMOBILE LAMP MFG.AGATE OR ENAMEL WARE MFG.ALUMINUM WARE MFG.WIRE ROPE OR CABLE MFG.WIRE DRAWINGWIRE CLOTH MFG.CHAIN MFG. - FORMED OR WELDED FIRE WIREBUTTONS OR FASTENERS MFG.-METALBED SPRING/WIRE MATTRESSAUTOMOBILE BUMPER MFG.HEAT TREATING - METALBRASS/COPPER GOODS MFG.COLLAPSIBLE WHITE METAL TUBE AND CAP MFG.CASTINGS MFG. - METAL - BY LOST WAX PROCESSELECTRIC WELDING OR CUTTINGDEBURRING - METALGALVANIZING OR TINNINGGOLD LEAF MFG.CAMERA REPAIRAUTO PARTS MFG. - MISCELLANEOUS STAMPED PARTSAGRICULTURAL IMPLEMENTS AND MACHINERYLOOM HARNESS OR REED MFG.ARMS MFG. NOCCONFECTION MACHINE MFG.ADDING, COMPUTING, RECORDING OFFICE MACHINERYAUTOMOBILE,BUS,OR TRUCK PARTS MFG.-OPERATING PARTSENGINE MFG. - OUTBOARD MOTORSBOILERMAKINGAUTOMATED MACHINE SHOP NOCMACHINE SHOP NOC.ACETYLENE TORCH MFG.GEAR MFG. OR GRINDINGBALL/ROLLER BEARING MFG.BATTERIES MFG. - DRY CELLELECT. POWER DISTRB/TRANSMISSION EQUPMT.MFG.NOCBATTERIES MFG. - WET CELL OR STORAGEAUTO LTG/IGNTN APPARATUS MFG.COMMUNICATION/RECRDG.SYST./EQPMT.MFG.-INDUS./COMMLINSTRUMENT MFG. NOCOIL STILL ERECTION OR REPAIRMACHINERY OR EQUIPMENT ERECTION OR REPAIRBOILER INSTALLATION OR REPAIRAIRPLANE WHEEL MFG.AUTOMOBILE RADIATORAUTOMOBILE MFG. OR ASSEMBLINGAUTOMOBILE DISMANTLINGAUTO, BUS, TRUCK, TRAILERAUTO, BUS, TRUCK, TRAILER NOCAIRCRAFT ENGINE MFG.AUTOMOBILE ENGINE MFG.AIRCRAFT OR AIRCRAFT PARTS MFG.MOTORCYCLE MFG./ASSEMBLYBABY CARRIAGE MFG.CAR MFG. - RAILROADCLAY OR SHALE DIGGINGBRICK MFG.BRICK MFG.CONCRETE PRODUCTS MFG & DRIVERSPLASTER BOARD OR PLASTER BLOCK MFG. & DRIVERSCONCRETE OR PLASTER PRODUCTS MFG.-NOT STRUCTURALCHINA, PORCELAIN OR EARTHENWARE MFG.CERAMICS MFG.CHINA, PORCELAIN OR EARTHENWARE MFG.GLASS MFG.INTEGRATED CIRCUIT MFGELECTRIC BULB MFGGLASS OR GLASSWARE MANUFACTURINGGLASS MFG. - CUTGLASS OR GLASSWARE MANUFACTURINGGLASS DEALERS AND GLAZIERSGLASS OR GLASSWARE MANUFACTURINGCATHEDRAL OR ART GLASS WINDOW MFG.OPTICAL GOODS MFG. NOCFIBER PULP MFG.PULP MFG - WOOD - SODA PROCESSBRISTOL BOARD MFG.BOX MFG. - SET-UP PAPERBOX MFG. - FOLDING PAPERBOXES OR CONTAINERS MFG. - CORRUGATED OR FIBERBOARCORK PAPER MFG - NO PAPER MANUFACTURINGCARBON PAPER OR INKED RIBBON MFG.FIBER GOODS MFG.BAG MFG. - PAPERBOX OR CASE LINING MFG-WATERPROOF PAPER FOR EXPORTBOOT OR SHOE PATTERN MFG.BUILDING PAPER PREPARATIONPRINTINGNEWSPAPER PUBLISHINGBOOKBINDINGENGRAVINGENGRAVINGFILM PRINT SHOPSRUBBER GOODS MFG. - NOCRUBBER TIRE MFG.PHONOGRAPH RECORD MFG.PEN MANUFACTURINGADVERTISING SIGNS MFG. - CELLULOIDPLASTIC MFG. - RAW MATERIALS NOCCABLE MFG.ADVERTISING DISPLAY MFG. - PLASTIC - INJECTION MOLFABRIC COATING/IMPREGNATING NOCANALYTICAL CHEMISTADHESIVES MFG.COLOR GRINDING, BLENDING, TESTINGSALT PRODUCING OR REFININGPHOSPHATE WORKSFERTILIZER DRY MIXING PLANTCOSMETICS MFG. - NOT MFG. INGREDIENTSACETYLENE GAS MFG.ADHESIVES MFG.COD LIVER OIL MFG.COTTONSEED OIL MFG.COTTONSEED OIL REFININGOIL MFG. - VEGETABLE - SOLVENT EXTRACTDENTAL LABORATORYARTIFICIAL LIMB MFGCORN PRODUCTS MFG.CANDLE MFG.BUTTER SUBSTITUTE MFG.SOAP MFG.GASOLINE RECOVERYASPHALT OR TAR DIST/REFININGCHEMICAL MFG. - COMMERCIAL OR INDUSTRIAL NOCEXPLOSIVES OR AMMUNITION MFG NOCBLASTING AGENTS - PREP/DISTDRUG MFG.CHEMICAL BLENDING OR MIXING NOCCHEMICAL MFG. NOC - ALL OPERATIONS & DRIVBASEBALL MFGBLUEPRINT PAPER MFGCEILING INSTALLATIONMASONRY NOCPAINTING - METAL BRIDGESIRON OR STEEL: ERECTION-FRAME STRUCTURESBLAST FURNACE ERECTIONIRON/STEEL: STRUCTURE UNDER 2 STORIESIRON/STEEL ERECTION-DWELLINGS UNDER 2 STORIESALUMINUM WINDOWS OR DOORS - NOT STORMFURNITURE OR FIXTURES INSTALLATIONELEVATOR ERECTION/REPAIRPLUMBING NOC AND DRIVERSFIRE EXTINGUISHING SYSTEMS - INSTALLATIONELECTRICAL WIRING W/IN BUILDING AND DRIVERSOFFICE MACHINE REPAIR AND INSTALLATIONVENDING OR COIN OPERATED MACHINES-INSTALLATION, SECONCRETE CONSTRUCTION NOC.CONCRETE CONSTRUCTIONCONCRETE OR CEMENT WORKBRIDGE OR ELEVATED HIGHWAY CONSTRUCTION-CONCRETESWIMMING POOL CONSTRUCTIONFLOOR LAYING - TILE, CERAMIC - INTERIOR ONLYGREENHOUSE ERECTIONCARPENTRY NOCCARPENTRY - INSTALL. CABINET WORK/INTERIOR TRIMLATHINGWALLBOARD INSTALLATION W/IN BUILDINGS & DRIVERSGLASS DEALERS AND GLAZIERSASBESTOS REMOVAL OPERATIONS:PIPE AND BOILER WORK EASBESTOS REMOVAL OPERATIONS:ASBESTOS CONTRACTOR -PAINTING OR PAPERHANGING NOCCARPET, LINOLEUM, VINYL FLOOR TILE INSTALACOUSTICAL MATERIAL INSTALLATIONPLASTERING NOC & DRIVERSPAPER HANGINGASPHALT - SPRAYING ROADS WITH LIQUID ASPHALTSTREET OR ROAD CONSTRUCTION OR RECONSTRUCTIONROCK EXCAVATION - STREET OR ROADSTREET OR ROAD MAINTENANCESHEET METAL WORK ? INSTALLATION & DRIVERS(FL) HEATING, VENTILATION, AIRROOFING - ALL KINDSCONTRACTING - EXECUTIVE SUPERVISORCLEANER - DEBRIS REMOVALCLEANER-DEBRIS REMOVAL-TEMPORARY LABOR SECARPENTRY - DETACHED DWELLINGSCARPENTRY - DWELLINGS - 3 STORIES/LESSBUILDING RAISING OR MOVINGSALVAGE OPERATION - NO WRECKINGANTI-TOXIN MFG.LAND PILE DRIVINGMARINE PILE DRIVING, DOCK & SEAWALL, JETTY OR BREAKWATER, DIKE OR REVETMENT CONSTRUCTION--ALL OPERATIONS TO COMPLETION & DRIVERSDAM OR LOCK CONSTRUCTION - CONCRETEDAM CONSTRUCTION - EARTH MOVINGDIKE, LEVEE OR REVETMENT CONSTRUCTIONDRILLING NOC & DRIVERSACIDIZING - ALL EMPLOYEES - OIL/GAS WELLSOIL OR GAS WELLS-SERVICING-BY CONTRACTORSOIL OR GAS WELLS-PERFORATING OF CASINGBUILDING OF LEVEES AND FIRE WALLSEXCAVATION AND DRIVERSIRRIGATION OR DRAINAGE SYSTEM CONSTRUCTIONOIL/GAS PIPELINE CONSTRUCTIONDRILLING OR REDRILLINGINSTALLATION OF CASINGSINSTRUMENT LOGGING/SURVEYTUNNELINGCAISSON OR COFFERDAM WORK-NOT FOUNDATIONS FOR BLDGSEWER CONSTRUCTION - ALL OPERATIONSGAS MAIN OR CONNECTION CONSTRUCTIONCABLE LAYING BY SPEC CONTRACTOR EMPLOYING AUTOMATIFENCE ERECTION - METALPOTATO CHIP, POPCORN & SNACK CHIP MFG. NOCBAKING POWDER MFG.RAILROAD CONSTRUCTIONRAILROAD CONSTRUCTION-ALL OPERATIONSRAILROAD CONSTRUCTION-ALL OPERATIONSBOAT BUILDING-WOOD-NOC & DRIVERS-COVERAGE UNDER U.S. ACTBOATBUILDING-WOOD-NOC & DRIVERS (STATE)BOAT BUILDING-OR REPAIR & DRIVERS-COVERAGE UNDER U.S. ACTMARINA & DRIVERS: COVERAGE UNDER U.S. ACTBOATBUILDING OR REPAIR-FIBERGLASS ONLY-AND DRIVERS-COVERAGE UNDER U.S. ACTBOAT BUILDING OR REPAIRMARINA & DRIVERSBOAT BUILDING OR REPAIR-FIBERGLASS ONLYSHIP BUILDING-IRON OR STEEL-NOC-& DRIVERS-COVERAGE UNDER U.S. ACTSHIP BUILDING-NAVAL & DRIVERSSHIP BUILDING-IRON OR STEEL-NOCSHIP REPAIR OR CONVERSION-ALL OPERATIONS & DRIVERS-COVERAGE UNDER U.S. ACTPAINTING: SHIP HULLS-COVERAGE UNDER U.S. ACTSHIP REPAIR CONVERSION (STATE ACT)PAINTING: SHIP HULLSVESSELS - NOCVESSELS - NOCBOAT LIVERYVESSELS - NOT SELF-PROPELLEDVESSELS - NOCBOAT LIVERY - BOATS UNDER 16 TONSBOAT LIVERY - BOATS UNDER 15 TONSVESSELS - NOT SELF - PROPELLEDVESSELS-NOT SELF PROPELLEDRAILROAD OPERATION NOCRAILROAD OPERATION - ALL EMPLOYEESRAILROAD OPERATION – ALL EMPLOYEES INCLUDING DRIVERS – PROGRAM II – USL ACT BENEFITSRAILROAD OPERATION – ALL EMPLOYEES INCLUDING DRIVERS – PROGRAM II – STATE ACT BENEFITSLIVERY OR BOARDING STABLEGREYHOUND BREEDING, TRAINING , RACING & DHORSE TRAININGTRUCKING - NOCTRUCKERSTRUCKERSTRUCKING: MAIL, PARCEL OR PACKAGE DELIVERYEXPRESS CO. - TRUCKINGSTEVEDORING NOCCOAL DOCK OPERATION & STEVEDORINGSTEVEDORING: BY HAND OR HAND TRUCKS EXCLUSIVELYSTEVEDORING: CONTAINERIZED FREIGHT & DRIVERSDREDGINGDREDGING - ALL TYPESDREDGING - ALL TYPESFREIGHT HANDLING NOC-COVERAGE UNDER U.S. ACTFREIGHT FORWARDERS OR HANDLERS NOCTAXI CAB CO. - ALL OTHER EMPLOYEES & DRIVERSDRIVERS, CHAUFFEURS & THEIR HELPERSBUS COMPANYCOLLEGE/SCHOOL BUS DRIVERBEER OR ALE DEALER - WHOLESALEDIVING - MARINEDIVING - MARINEDIVING-MARINEAIR TRAFFIC CONTROLLERS UNDER CONTRACT WITH FAAAIR CARRIER - SCHEDULEDAIR CARRIER/SCHEDULED - FLYING CREWAIRCRAFT - PUBLIC EXHIBITION: FLYING CREWAIRCRAFT - TRANSP/PERSONNELAIRCRAFT - NOC/HELICOPTERS: FLYING CREWAIRCRAFT - HELICOPTER: FLYING CREWAIR CARRIER/COMMUTER - FLYING CREWNON-RATABLE CATASTROPHE LOADING FOR 7405NON-RATABLE CATASTROPHE LOADING FOR 7431GAS CO. - NATURAL GASOIL/GAS PIPELINE OPERATIONSWATER COMPANIESELEC./POWER LINE CONSTR ON TRANS LINES NOT FOR LOCELECTRIC LIGHT OR POWER COMPANIESELECTRIC LIGHT OR POWER COOP - RURAL ELECT. ADMINSMUNICIPAL SEWAGE DISPOSAL PLANTS - OPERATIONGARBAGE WORKSTELEPHONE/ TELEGRAPHALARMS & ALARMS SYSTEMS-INSTAL.,SRVCG. AND REPAIRRADIO OR TELEVISION BROADCASTING STATION-ALL EMPLOFIRE DEPARTMENTSAMBULANCE SVC COMPANIES, EMS PROVIDERS & DRIVERSPOLICE OFFICERS AND DRIVERSLAYING TRACKS/MAINTENANCEFLORIST STOREAUTO RENTAL COMPANYSTORE: GROCERY RETAILSTORE: CLOTHING/APPAREL - RETAILSTORE: HARDWARESTORE: JEWELRYQUICK PRINTING-COPYING OR DUPLICATION SERRETAIL STORES & GROCERYSTORE: WHOLESALE NOCMEAT DEALER - WHOLESALECOLD STORAGE LOCKERSTORE: CLOTHING, WHOLESALEGROCERY STORESSTORE?SUPERSTORES AND WAREHOUSE CLUBSDEPARTMENT OR DISCOUNT STORESSTORE: FURNITURE & DRIVERSSTORE: DRUG RETAILAUTO ACCESSORIES STORE - RETAILDRUG DISTRIBUTORSBUILDING MATERIAL DEALER - STORE EMPLOYEESGROCERY STORE - CONVENIENCE - RETAILSTORE: BOOK, RECORD, COMPACT DISC, AUDIO,BEAN SORTING OR HANDLINGCLIPPINGS DEALERIRON OR STEEL MERCHANTCONTRACTOR'S MACHINERY DEALERGAS, STEAM AND HOT WATER APPARATUS - SUPPLIES DEALFARM MACHINERY DEALERICE DEALERBUILDING MATERIAL DEALERS - SECONDHAND MATERIALPRODUCE HANDLING OR PACKINGFEED, GRAIN OR HAY DEALERSCONSTRUCTION OR ERECTION - PERMANENT YARDBUILDING MATERIAL DEALER - NEW MATERIALSCOAL MERCHANTBUILDING MATERIAL DEALERSJUNK DEALERBOTTLE DEALER - USEDIRON/STEEL SCRAP DEALERHORSE BREEDING INVOLVING STALLIONS – & DRIVERSHORSE BREEDING NOT INVOLVING STALLIONS – & DRIVERSBREEDING FARM OR STABLECATTLE DEALERSTORAGE WAREHOUSE - COLDSTORAGE WAREHOUSE NOCFURNITURE MOVING/STORAGEGRAIN ELEVATOR OPERATIONGASOLINE DEALERS & DRIVERSGAS DEALER - L.P.G. & SALES, DAUTO SERVICE AND REPAIR CENTERGAS STATIONS SELF AND FULL SERV.AMBULANCE SERVICE COMPANIES: GARAGE EMPLOYEESAUTOMOBILE PARKING LOTAUTOMOBILE BODY REPAIRMETAL SCRAP DEALERARCHITECTS OR ENGINEER CONSULTINGSURVEYORS, OIL OR GAS GEOLOGISTS, SCOUTS, DRIVERSARCHITECTURAL OR ENGINEERING FIRM?CLERICALGEOPHYSICAL EXPL.- SEISMICSTEVEDORING-TALLIERS AND CHECKING CLERKS ENGAGED IN CONNECTION WITH STEVEDORE WORK-COVERAGE UNDER U.S. ACTSTEVEDORING: TALLIERS AND CHECKING CLERKS ENGAGEDINSPECTION OF RISKS FOR INSURANCE OR VALUATIONREAL ESTATE APPRAISAL CO.INSURANCE COMPANIES - INCLUDING CLERICAL & SALESPERSONSARCHITECTURAL OR ENGINEERING INVENTORY COUNTERSSTEAMSHIP LINE OR AGENCY-PORT EMPLOYEES: SUPERINTENDENTS, CAPTAINS, ENGINEERS, STEWARDS OR THEIR ASSISTANTS, PAY CLERKSINSURANCE - OUTSIDE CLAIM ADJUSTERSSALESPERSONS, COLLECTORS, OR MESSENGERS – OUTSIDE – PROGRAM II – STATE ACT BENEFITSRAILROAD OPERATION - SALESPERSONSSALESPERSONS, COLLECTORS, OR MESSENGERS – OUTSIDE – PROGRAM II – USL ACT BENEFITSSALESPERSONS, MESSENGERSNEWS AGENT/DISTRIBUTOR OF MAGAZINESAUTOMOBILE SALESPERSONSLABOR UNION - ALL EMPLOYEESMAILING OR ADDRESSING COMPANY OR LETTER SERVICE SHOP - CLERICAL STAFFMAILING OR ADDRESSING CO OR LETTER SERVICE SHOPACCOUNTANT, AUDITOR, FACTORY COST SYST.CLERICAL OFFICE EMPLOYEES – NOC – PROGRAM II STATE ACT BENEFITSCLERICAL OFFICE EMPLOYEESRAILROAD OPERATIONS - CLERICALCLERICAL OFFICE EMPLOYEES – NOC – PROGRAM II USL ACT BENEFITSATTORNEY - ALL EMPLOYEESHEALTH CARE FAC. HOME/AGED NOT/PRO.HEALTH CARE FAC. HOME/AGED NOT/PRO.HEALTH CARE FAC. HOME/AGED NOT/PRO.CONVALESCENT/NURSING HOMEHOSPITAL - VETERINARY AND DRIVERSMEDICAL OFFICES, PHYSICIANHOSPITAL: PROFESSIONAL EMPLOYEESNURSING - HOME HEALTHNURSING HOME: PROFESSIONALGROUP HOMES?ALL EMPLOYEES & SALESPERSONS, DRIVERSBANKS AND TRUST COMPANIES - ALL EMPLOYEES, SALESPERSONS, DRIVERS & CLECHECK CASHING ESTABLISHMENTS - ALL EMPLOYEES, SALESPERSONS, DRIVERS &SOCIAL SERVICES EMPLOYEES, SALESPERSONS, DRIVERSCOLLEGE: PROFESSIONAL EMPLOYEES & CLERICALCHILD CARE CENTERCLERICAL TELECOMMUTER EMPLOYEESCABLE T.V. COMPANIES: CLERICAL EMPLOYEESBUILDING OPS BY OWNER, LESSEE, REAL ESTATE MGMT COBUILDINGS - OPERATION BY CONTRACTORBUILDINGS OPERATION/MAINT.AMUSEMENT PARK/EXHIBITIONBRIDGE/VEHICULAR TUNNELHOUSING AUTHORITYHOSPITAL: ALL OTHER EMPLOYEESNURSING HOME: ALL OTHER EMPLOYHOTEL: ALL OTHER EMPLOYEES & SALES PERSONS, DRIVERHOTEL: RESTAURANT EMPLOYEESCLUB - COUNTRYCLUB NOC AND CLERICALYMCA, YWCA, YMHA OR YWHA INSTITUTIONUNITED STATES ARMED SERVICE RISK-ALL EMPLOYEES & DRIVERSRESTAURANT NOCRESTAURANT: FAST FOODBAR, DISCOTHEQUE, LOUNGE, NIGHT CLUB OR TAVERNBILLIARD HALLBOWLING ALLEYS - AUTOMATICCOLLEGE: ALL OTHER EMPLOYEESPARK NOC - ALL EMPLOYEES & DRIVERSTHEATER NOC: ALL OTHER EMPLOYEESTHEATER NOC: PLAYERS, ENTERTAINERSJANITORIAL SVC BY CONTRACTORS?INCLUDES WINDOWSATHLETIC SPORTS OR PARK:NON-CONTACT SPORTSATHLETIC SPORTS OR PARK:CONTACT SPORTSAMUSEMENT DEVICE OPERATIONATHLETIC SPORTS OR PARK:OPERATIONS & DRIVERSCARNIVAL OR CIRCUS COMPANIESCEMETERIESCESSPOOL CLEANING - SPECIALIST CONTRACTORSGARBAGE AND REFUSE - COLLECTING IN CONTAINERSBOARD OF HEALTH INSPECTORSPAINTING: SHOP ONLY & DRIVERSAUTO,BUS,TRUCK,TRAILER: PAINTINGRADIO TELEVISION ANTENNA SERVICEAIR CONDITIONING SYSTEMS:PORTABLE UNITS-INSTL'N ORHOUSE FURNISHING INSTALLATION NOCAUTO,BUS,TRUCK,TRAILER: UPHOLSTERINGBELL INSTALLATIONSIGN INSTALLATION, MAINTENANCE, REPAIRBARBER OR BEAUTY PARLOR SCHOOLSTAXIDERMISTCREMATORIES
Number of Employees
Annual Payroll
How many office employees?
Do you currently have Workers Compensation? YesNo
When does it expire.
Who is the Insurance Company?
Any claims in the last 3 years YesNo
How much paid
Does applicant own, operate or lease any aircraft/watercraft? YesNo
Please Explain
Any past, present or discontinued operations, which involve exposure to chemicals, lead based paint, or hazardous materials? YesNo
Any work performed under, on, or above water? YesNo
Any work which may be subject to Jones Act, USL&H, or FELA? YesNo
Any work performed underground or higher than 15 feet above ground level? YesNo
Detail max. height and max. depth
Any operations include excavation, tunneling, road boring, earth moving, or other underground work? YesNo
Any fatalities in the past five years? YesNo
Is applicant involved in any business other than that specified in the description of operations? YesNo
Do employees travel out of state or out of the country? If so, scope of travel? YesNo
Are any group travel or ride-sharing programs provided? YesNo
Does the radius of operations vehicles exceed 200 miles? YesNo
Are MVRs checked on all drivers? YesNo
Is a written safety program in place? YesNo
Has applicant been inspected by OSHA in the past three years? YesNo
Was applicant cited for any violations? YesNo
Was applicant fined? YesNo
If so, how much?
Are any subcontractors used? YesNo
what percentage of work is subcontracted? Also, what type of work is subcontracted?
If any tree trimming work is performed, are any climbers or bucket trucks used? YesNo
If any roofing work is performed, is any hot tar or hot mops used? YesNo
what is the percent of all work performed?
Please provide the percentages of commercial and residential work.
Commercial % (if not applicable, type 0)
Residential % (if not applicable, type 0)
Any prior coverage declined, cancelled or non-renewed in the past three (3) years? YesNo
Please provide details
Workers’ Compensation Loss History Affidavit
I,,do hereby verify and swear that has incurred injuries within the last 36 months.
Company Name:
Signature: Clear
Date:
Title/Position:
Any person who knowingly and with intent to injure, defraud, or deceive and insurer files, statement of claim, or an application containing any false, incomplete, or misleading information with the purpose of avoiding or reducing the amount of premiums for workers compensation coverage or conceal information pertinent to the computation and application of an experience rating modification factor, is guilty of a felony of the third degree or as otherwise punishable as provided under the law.
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