Workers’ Compensation Liability Application : Western Bowling Proprietors Insurance

Entity Name to be Listed as First Named Insured (The Business’s Legally Filed Name)

Is this business an Incorporation, LLC, Partnership, or Individual entity?

Incorporation,
LLC
Partnership
Individual entity

Owner/Officers/Partner(s) Name(s)

Years Owned

Years of Bowling Management Experience

Address

City

State

Zip / Post Code

Phone

Fax

Email

Website

Contact Person

Title

Phone

Insured/Applicant Social Security # or Federal EIN #

Current Comp Insurer

Expiration Date

Annual Premium

Name, Title, Birthdate, Exclude/Include in Coverage?, Ownership%

Estimated Total Annual Payroll

Payroll for Clerical (Class Code 8810)

No. of Clerical Employees

Payroll for Bowling Employees

No. of Bowling Employees

Payroll for any Outside Sales Employees

No. of Outside Sales Employees

“Other Classes” Payroll to be Included

No. of other class code employees

For “Other Classes” listed above, what is the class code used by your current Comp Carrier?

Any Assigned Modification Rate(s)? (experience mod, schedule mod, etc)

Any Significant Losses in Past 4 Years

Yes
No

Details Below (Amount Paid, Month/Year)

1. Does the applicant own, operate, or lease aircraft/watercraft?

Yes
No

2. Do you have past, present, or discontinued operations involved in storing, treating, discharging, applying, disposing, or transporting hazardous materials?

Yes
No

3. Any work performed underground or above 15ft?

Yes
No

4. Any work performed on barges, vessels, docks, or bridges over water?

Yes
No

5. Is applicant engaged in any other type of business?

Yes
No

6. Are subcontractors used?

Yes
No

If Yes, give % of work subcontracted

7. Any work sublet without certificates of insurance?

Yes
No

8. Is a written safety program in operation?

Yes
No

9. Any group transportation provided?

Yes
No

10. Any employees under 16 or over 60 years of age (excluding owners)?

Yes
No

11. Any seasonal employees?

Yes
No

12. Is there any volunteer or donated labor?

Yes
No

If Yes, specify in remarks.

13. Any employees with physical/mental handicaps?

Yes
No

14. Do employees travel out of state?

Yes
No

If yes, specify in remarks.

15. Are athletic teams sponsored?

Yes
No

16. Are physicals required after offers of employment are made?

Yes
No

17. Any prior coverage declined/cancelled/non-renewed in the last 3 years?

Yes
No

18. Are employee health plans provided? If Yes, specify in remarks.

Yes
No

If Yes, specify in remarks.

19. Do employees perform work for other businesses or subsidiaries?

Yes
No

20. Do you lease employees to or from other employers?

Yes
No

21. Do any employees predominantly work at home?

Yes
No

If Yes, Number

22. Any tax liens or bankruptcy within the last 5 years?

Yes
No

23. Any disputed or unpaid workers compensation premium due from you or any commonly managed or owned enterprises?

Yes
No

Remarks

Anti-Spam: What is 6 plus 9? *

Workers’ Compensation Liability Application

Download the WBPI Workers Comp Application or fill in the form below.