Workers’ Compensation Liability Application Download the WBPI Workers Comp Application or fill in the form below. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required WBPI Workmen’s Compensation Application 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,LLCPartnershipIndividual entity Owner/Officers/Partner(s) Name(s) Years Owned Years of Bowling Management Experience Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 All Partner/Co-Owners Names and Interest 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 YesNo Details Below (Amount Paid, Month/Year) Please Answer the following yes or no questions 1. Does the applicant own, operate, or lease aircraft/watercraft? YesNo 2. Do you have past, present, or discontinued operations involved in storing, treating, discharging, applying, disposing, or transporting hazardous materials? YesNo 3. Any work performed underground or above 15ft? YesNo 4. Any work performed on barges, vessels, docks, or bridges over water? YesNo 5. Is applicant engaged in any other type of business? YesNo 6. Are subcontractors used? YesNo If Yes, give % of work subcontracted 7. Any work sublet without certificates of insurance? YesNo 8. Is a written safety program in operation? YesNo 9. Any group transportation provided? YesNo 10. Any employees under 16 or over 60 years of age (excluding owners)? YesNo 11. Any seasonal employees? YesNo 12. Is there any volunteer or donated labor? YesNo If Yes, specify in remarks. 13. Any employees with physical/mental handicaps? YesNo 14. Do employees travel out of state? YesNo If yes, specify in remarks. 15. Are athletic teams sponsored? YesNo 16. Are physicals required after offers of employment are made? YesNo 17. Any prior coverage declined/cancelled/non-renewed in the last 3 years? YesNo 18. Are employee health plans provided? If Yes, specify in remarks. YesNo If Yes, specify in remarks. 19. Do employees perform work for other businesses or subsidiaries? YesNo 20. Do you lease employees to or from other employers? YesNo 21. Do any employees predominantly work at home? YesNo If Yes, Number 22. Any tax liens or bankruptcy within the last 5 years? YesNo 23. Any disputed or unpaid workers compensation premium due from you or any commonly managed or owned enterprises? YesNo Remarks You will need to order your loss runs from you current carrier immediately. Anti-Spam: What is 6 plus 9? *
Download the WBPI Workers Comp Application or fill in the form below. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required WBPI Workmen’s Compensation Application 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,LLCPartnershipIndividual entity Owner/Officers/Partner(s) Name(s) Years Owned Years of Bowling Management Experience Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 All Partner/Co-Owners Names and Interest 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 YesNo Details Below (Amount Paid, Month/Year) Please Answer the following yes or no questions 1. Does the applicant own, operate, or lease aircraft/watercraft? YesNo 2. Do you have past, present, or discontinued operations involved in storing, treating, discharging, applying, disposing, or transporting hazardous materials? YesNo 3. Any work performed underground or above 15ft? YesNo 4. Any work performed on barges, vessels, docks, or bridges over water? YesNo 5. Is applicant engaged in any other type of business? YesNo 6. Are subcontractors used? YesNo If Yes, give % of work subcontracted 7. Any work sublet without certificates of insurance? YesNo 8. Is a written safety program in operation? YesNo 9. Any group transportation provided? YesNo 10. Any employees under 16 or over 60 years of age (excluding owners)? YesNo 11. Any seasonal employees? YesNo 12. Is there any volunteer or donated labor? YesNo If Yes, specify in remarks. 13. Any employees with physical/mental handicaps? YesNo 14. Do employees travel out of state? YesNo If yes, specify in remarks. 15. Are athletic teams sponsored? YesNo 16. Are physicals required after offers of employment are made? YesNo 17. Any prior coverage declined/cancelled/non-renewed in the last 3 years? YesNo 18. Are employee health plans provided? If Yes, specify in remarks. YesNo If Yes, specify in remarks. 19. Do employees perform work for other businesses or subsidiaries? YesNo 20. Do you lease employees to or from other employers? YesNo 21. Do any employees predominantly work at home? YesNo If Yes, Number 22. Any tax liens or bankruptcy within the last 5 years? YesNo 23. Any disputed or unpaid workers compensation premium due from you or any commonly managed or owned enterprises? YesNo Remarks You will need to order your loss runs from you current carrier immediately. Anti-Spam: What is 6 plus 9? *