Supplemental Application

Workers’ Compensation To be completed with ACORD 130 Application

Named Insured: Web Address:

Insured’s FEIN:
CONTACT NAME PHONE NUMBER
Inspections:
Premium Audit:
Claims:
PRIOR PAYROLL AND PREMIUM INFORMATION
Total Annual Payroll Premium $
Current Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:
OPERATIONS AND BENEFITS
Broker controlled account? Yes No
Does applicant currently use a PEO or payroll service? Yes No If yes, provide name of organization used:
Please provide a detailed description of the operation:

Years in business? Hours of operation:

No. of shifts: Does the applicant allow employees to work more than three consecutive 12-hour shifts? Yes No
Is there a driving or delivery exposure? Yes No Radius of operations/travel: <10 miles 11-50 50-100 100+
If yes, what is the frequency? Daily Weekly Other: Any group transportation of employees? Yes No
Is a PUC/DMV filing required? PUC DMV N/A If yes, how provided? Car Truck Van Bus
Are vehicles company owned? Yes No No. of employees transported per vehicle:
If yes, types of vehicles: No. of vehicles used to transport:
If yes, are vehicles taken home: Yes No Frequency: Daily Weekly Monthly
No. of vehicles: No. of drivers: Is insured enrolled in DMV Pull program? Yes No
Vehicle/fleet maintenance program? Yes No Are driver acceptability standards in place? Yes No
If yes, who does the servicing? If yes, provide details:
Outside vendor:
In-house mechanics:
Other:
Does insured have and enforce the following policies for drivers:
Alcohol/drug use: Yes No Seat belt use: Yes No Distracted driving: Yes No
Any work-related injuries as a result of a prior motor vehicle accident within the past four years? Yes No
If yes, please provide details, including fault of accident and if subrogation was pursued:

Do employees use personal vehicles for company business? Yes No

Do any employees work from home? Yes No No. of employees who live/work out of state: Live: Work:
Any out-of-state, international or overnight (within state) travel? Yes No If yes, provide details:
Why/purpose?
Who will travel? Where? Duration? Frequency?
No. of employees: (verify number is Full: Part: Seasonal: Volunteers:
consistent w/ number on ACORD application)
No. of employees per location: 1. 2. 3. 4. Use a separate page if needed.
Average annual employee turnover: _________________________% No. of W-2s issued: Last Year: Previous Year:
How are employees paid? Hourly: Piece rate: Commission: Flat Salary: Other:
Any interchange labor? Yes No If yes, please explain: __ Another business __ Subsidiary__ Between departments __ Other

GROW with us ® | 701 B Street, Suite 2100, San Diego, CA 92101 | Tol 800.669.1889 x8733 | ArrowheadGrp.com | CA License #0699809
Any day laborers or temporary/employee leasing? Yes No
% of union employees: Average hourly wage for employees in governing class: $
%of non-union: Retirement/pension plan? Yes No Does employer contribute? Yes No
Group medical provided? Yes No If group medical is provided, who is the healthcare provider?
% of employees enrolled: % paid by employer:
Do you have a wellness program (ie encourages and promotes employee health programs) in place? Yes No
Do you provide paid sick leave? Yes No Paid vacation? Yes No
Do you use a specific medical provider to treat injured employees? Yes No
Are you currently participating in a MPN (Medical Provider Network)? Yes No
If yes, please provide the name of current MPN:
CPR training provided? Yes No Return to Work Program (RTW) in place? Yes No
No. of employees certified? Does it include salary continuation? Yes No
Has the ownership of the applicable entity changed within the past five years? Yes No
If yes, please provide details:
HIRING PRACTICES - EMPLOYEE SELECTION - CLAIMS
Written application? Yes No Pre-hire drug testing? Yes No
Reference checks? Yes No Post-accident drug testing? Yes No
Background checks? Yes No MVR checks? Yes No
Pre/post employment physicals? Yes No Audio hearing tests? Yes No
Orthopedic back testing? Yes No Do you have a formal written accident report? Yes No
Formal job descriptions on file? Yes No Are there set procedures for reporting claims? Yes No
Average claim reporting time frame: Are supervisors held accountable for injuries/accidents? Yes No
Is job specific training provided? Yes No

Employee Orientation Program? Yes No If yes, is the orientation: Verbal only? Verbal and Documented?
Employee to Supervisor ratio: Better than 4-1 5-1 6-1 7-1 >7-1
Subcontractors used? Yes No If yes, for what purpose?
If yes, are certificates of insurance obtained and kept on file? Yes No
Independent contractors used? Yes No If yes, for what purpose?
If yes, how are they paid? 1099s? Other? Please explain.
SAFETY PROGRAM AND ORGANIZATION - WORK PREMISES AND ENVIRONMENT
Are owners active in daily operations? Yes No If yes, are they excluded from coverage? Yes No
Active injury & illness prevention program? Yes No Heat illness prevention program? Yes No
Active safety incentive program? Yes No Has loss control services been performed in the last year? Yes No
If yes, does it encompass all employees? Yes No Has Cal/OSHA visited/cited your business in the last year? Yes No
What type of incentive? If yes, please provide explanation on separate page.
Do employees receive safety training/orientation? Yes No Are safety meetings conducted? Yes No
If yes, is the training: Formal / Documented Informal If yes, how often? Daily Weekly Monthly Quarterly Other
Do you have a safety director or risk manager? Yes No Name and title:
If yes, is the position full time or an additional responsibility of another employee?
MSDS (Material Safety Data Sheets) available for all chemicals and products used? Yes No N/A
Any material handling exposures? Yes No If yes, please explain:
Any lifting exposures? Yes No Forklift training provided? Yes No N/A
If yes, <25 lbs. 25-40 40+ If yes, annual certification? Yes No
If 40+, manual lifting or with assistance? Explain:
Is all machinery/equipment properly guarded? Yes No N/A Any use of Baler equipment? Yes No
Written lockout/tagout/blockout procedures in place?
Condition of equipment? New Good Average
Yes No N/A
Respiratory program in place? Yes No Age of equipment? 0-5 years 5-10 10-20 20+
What is the maximum height in feet you will work? Please see Contractors Section for further elaboration.
What is used? Ladder Scaffolding Scissor lifts N/A If scaffolding used, does the insured build their own? Yes No
If insured builds own scaffolding, provide % of annual operations involving scaffold setup and teardown compared to total operations:
Written Fall Protection Program? Yes No Please see Contractors Section for further elaboration.
Are all equipment operators trained/ certified? Yes No N/A Personal protection equipment provided? Yes No N/A
Is the building/premises: Owned Leased? If yes, strict enforcement of utilization? Yes No
Condition of premises? Excellent Very good Average What types of PPE?
No. of years at current location? Number of years of building occupied?
 AUTOMOTIVE REPAIR / TOWING
Are you a member of an Association? Yes No If yes, provide list of Associations:

Types of vehicles serviced: Private Passenger Motorcycles Commercial Vehicles >15K Gross Vehicle Weight Rating Motorhomes
Buses Commercial Vehicles>25K Gross Vehicle Weight Rating Trailers All Terrain
Any test driving of customer’s vehicles? Yes No
Any transportation of customers provided? Yes No If yes, what radius?
Services include tire repair/sales/installation? Yes No If yes, amount of total operation___% If above 10%, complete Tire Section.
Any transmission rebuilding? Yes No What % of total operations? ______%
Any engine rebuilding? Yes No What % of total operations? ______%
What equipment is utilized to lift heavier auto parts?
Are employees Automotive Service Excellence trained & certified? Yes No If yes, what percentage of total workforce? ______%
Number or percentage of Master Technicians on staff _______
Any mobile operations? Yes No If yes, what percentage of total operation is mobile? ________%
Services include towing? Yes No
If yes, is towing for Customers only? Highway Patrol? Municipalities? AAA? Other? If other, provide details:

What percentage of total operations involves towing____%

What is towing radius? 50 miles 51-100 miles 101-250 miles +250miles
Types of vehicles towed: Private Passenger Motorcycles Commercial Vehicles >15K Gross Vehicle Weight Rating Motorhomes
Buses Commercial Vehicles>25K Gross Vehicle Weight Rating Trailers All Terrain
24 hours towing provided? Yes No Are tow trucks equipped with scanners? Yes No
Roadside repair operations? Yes No Are tow trucks equipped with GPS tracking? Yes No
Hours of roadside repair? What percentage of total operations?_____%
Do drivers carry firearms? Yes No Any accident scene recovery operations? Yes No
Any vehicle repossession operations? Yes No Any underwater recovery? Yes No
AUTO BODY REPAIR
Are you a member of an Association? Yes No If yes, provide list of Associations:

Types of vehicles serviced: Private Passenger Motorcycles Comm’l Vehicles >15K Gross Vehicle Weight Rating Motorhomes
Buses Comm’l Vehicles>25K Gross Vehicle Weight Rating Trailers All Terrain
Are employees Automotive Service Excellence trained & certified? Yes No If yes, what percentage of total workforce? ______%
Is applicant an I-Car Gold Member? Yes No What percentage of technicians are I-Car certified? _____%
Do you belong to a Direct Repair Program (DRP)? Yes No If yes, list endorsing insurance carriers:

Paint booth used? Yes No Is paint booth properly filtered/ventilated? Yes No

Is it UL certified? Yes No Are flammables stored inside the booth? Yes No
Formal written respiratory program in place? Yes No Does the booth have automatic fire suppression? Yes No
Are employees properly trained in use of respiratory equipment? Yes No
Has proper fit testing been provided to each employee and their assigned respirator? Yes No
Do employees complete a medical evaluation questionnaire? Yes No
If yes, is it reviewed by a physician? Yes No
Any mobile operations? Yes No If yes, what percentage of total operation is mobile? ________%
Any test driving of customer’s vehicles? Yes No
Any transportation of customers provided? Yes No If yes, what radius?
Any towing services provided? Yes No If yes, please complete all towing-related questions in above section.
 AUTO SERVICE STATION
Are you a member of an Association? Yes No If yes, provide list of Associations:

Pumps: Full Service? Yes No Self Service? Yes No Do services include auto repair? Yes No
If yes, please complete above auto repair section.
Is there a car wash on premises? Yes No Is it automated? Yes No
Is the cashier’s booth bullet proof? Yes No Drop safe registers? Yes No
Any security/surveillance cameras on premises? Yes No Are operations 24 hours? Yes No
Is there a mini market on premises? Yes No Any sales of alcoholic beverages? Yes No
Access to freeway? 0-1 mile 1-2 miles +2 miles
Any mobile operations? Yes No
If yes, what percentage of total operation is mobile? ______%
AUTO PARTS
Are you a member of an Association? Yes No If yes, provide list of Associations:

Be sure to complete delivery/driving exposure questions on page 1 of this supplemental application.

Gross receipts wholesale? ____% Gross receipts retail? ____%
Any assembly? Yes No If yes, provide details:
Is product palletized? Yes No
Max weight lifted manually? _______lbs Lifting exposure or repackaging? Yes No
Use of forklifts? Yes No Are operators trained & certified? Yes No
List other mechanical devises for lifting:
TIRE SERVICE
Are you a member of an Association? Yes No If yes, provide list of Associations:

Types of vehicles serviced: Private Passenger Motorcycles Commercial Vehicles >15K Gross Vehicle Weight Rating Motorhomes
Buses Commercial Vehicles>25K Gross Vehicle Weight Rating Trailers All Terrain
Any mobile operations? Yes No If yes, what percentage of total operation is mobile? ________%
Any retreading operations? Yes No Any recapping operations? Yes No
Split rim servicing? Yes No Are tire safety cages utilized when inflating? Yes No
Max weight lifted manually? _____lbs Use of forklifts? Yes No
Are operators trained & certified? Yes No
AUTO DISMANTLING
Are you a member of an Association? Yes No If yes, provide list of Associations:

Types of vehicles dismanted: Private Passenger Motorcycles Commercial Vehicles >15K Gross Vehicle Weight Rating Motorhomes
Buses Commercial Vehicles>25K Gross Vehicle Weight Rating Trailers All Terrain
Are vehicle tanks drained of gas and other automotive fluids at time of vehicle arrival at facility? Yes No
Who removes air bags? If insured’s employees, is any special training provided? Yes No
Any vehicle crushing operations? Yes No
Any stacking of vehicles? Yes No If yes, provide max height of stacking _____ft.
Any dogs on premises for security or other reasons? Yes No
If yes, provide details:
Any welding performed? Yes No
If yes, you must complete the Welding Exposure Supplemental App and include it with your submission. Visit ArrowheadGrp.com for the form >>
Use of forklifts? Yes No Are operators trained and certified? Yes No
List other mechanical devises for lifting:

Thank you.

06.26.2017