Thank you for considering IRRMA for your workers’ compensation coverage. We have tried to make the application process as easy as possible. The Illinois Restaurant Risk Management Association will accept either of two formats for an underwriting submission (both are included with this material). 1. Submission of a fully completed ACORD Application and IRRMA ACORD Application Supplement. (Five years of Loss Runs must accompany the submission and/or be provided prior to binding coverage.) 2. Completion and submission of the IRRMA Quick Survey and IRRMA ACORD Application Supplement. NOTE: We will require hard copies of supporting data (loss runs, experience modifiers and payroll audits) to finalize coverage. Please return to: CCMSI 2 East Main St. Danville, IL 61832 800-252-5059, ext. 1248 217-444-2498 – Fax QUICK SURVEY ILLINOIS RESTAURANT RISK MANAGEMENT ASSOCIATION (IRRMA) Company Name: _____________________________________________________________________ Address: _____________________________________ Phone: _______________________________ City, State, Zip:________________________________ Fax: _________________________________ Contact Person/Title: _________________________________________________________________ Locations (#) in IL: _____________________________ # of Employees in IL: __________________ Locations (#) outside IL: ________________________ # of Employees outside IL: ______________ What other states do you operate in? ____________________________________________________ Do officers elect Workers’ Compensation coverage? ______________________________________ If no, please provide names and titles of officers below. ____________________________________________________________________________ ____________________________________________________________________________ PAYROLL INFORMATION Please provide projected payrolls by class code for the upcoming policy year. Class Code Payroll $ Class Code Payroll $ Class Code Payroll $ LOSS INFORMATION Please provide five years of historical loss experience if available (minimum of 3 years required). Year 2007 2006 2005 2004 2003 # Claims $ Paid $ Reserve $ Total Incurred Value Date CURRENT POLICY INFORMATION Current Carrier:_________________ Expiration Date:_________ Assigned Risk Pool? Y N Type of Policy:__________________ Estimated Annual Premium $ ____________________________ (Guaranteed Cost/High-Low/Retro/Self-Ins./High Deduct. Other) (ATTACH A COPY OF POLICY DECLARATIONS) IRRMA ACORD APPLICATION SUPPLEMENT PART 1 General Company Information: 1. Are you currently a member of the Illinois Restaurant Association? Member #_______ 2. How many years in the business? 3. Date of opening under current owners:______ Note: If new operation, please provide information concerning owner’s/manager’s prior restaurant experience. 4. Type of restaurant? 5. Do you have a catering operation? If so, % of gross receipts. YES NO COMMENTS 6. Do you have a delivery service? If so, % of gross receipts. 7. Do you have banquet facilities? If so, % of gross receipts. 8. Is your business located within another place of business? For example do you have concessions within a grocery store? 9. Hours of operation? 10. Seating capacity:______ Lounge capacity:______ 11. How many levels in the building? 12. Is any work performed on barges, vessels, docks, bridge over water? 13. Any entertainment? 14. Estimated gross annual sales: Food _____ Liquor _____ 15. Were you ever cancelled/declined/non-renewed for workers’ compensation? Employee Information: 1. Number of full time employees:_____ part time:_____ Number of bilingual employees:_____ Is there an interpreter on staff? Include how many servers, host, kitchen staff, bus staff and mgt. 2. Are pre-employment physicals required? Employee Information (Continued): 3. Is there any volunteer or donated labor? 4. Are uniforms worn? What type of shoes? 5. Is safety orientation provided? 6. Is training for lifting provided? Equipment Information: YES NO COMMENTS YES NO COMMENTS Quantity of Equipment Guards in place? Comments: 1. 2. 3. 4. 5. 6. 7. 8. Freezer: Cooler: Oven: Fryer: Slicer: Dough/pasta machine: Mixers: Other equipment: Vehicle Information: Quantity of this type of vehicle List what vehicle is used for: 1. List type of vehicles (i.e. cars, vans, trucks) YES 2. How many drivers?______ 3. MVR obtained for each driver? Administrative Safety/Security: 1. Who is the assigned workers’ compensation claims handling person? 2. Is a formal Safety Program in operation? 3. Is there an established Safety Committee? 4. Is annual safety training provided? 5. Are formal inspections conducted? NO COMMENTS 6. What are your Accident Investigation procedures? 7. Is light duty provided? 8. Are First Aid kits provided? 9. What are your closing procedures/doors locked secure? Kitchen/Restaurant Safety: Slip/Trip/Fall 1. Please describe your floor surfaces (front/back): YES NO COMMENTS 2. Are rubber mats/non-slip floor coverings provided (front/back): 3. Are stairways maintained and handrails provided? 4. What are your procedures for spills/wet floors? 5. Are wet floor signs provided? Cuts/Lacerations 1. Is there training for food prep personnel and how often? 2. Is Personal Protective Equipment provided such as gloves? 3. Is lockout/tagout of equipment (food slicers, mixers, etc.) enforced? Burns 1. Is Personal Protective Equipment provided for burns? IRRMA ACORD APPLICATION SUPPLEMENT PART 2 General Information Provide Names and Addresses of each of your locations: Location Address City, State, Zip Payroll Information Provide audited payroll figures for the past four (4) years and current year. Plan year beginning: 2003 ________________________________________________________________________ 2004 ________________________________________________________________________ 2005 ________________________________________________________________________ 2006 ________________________________________________________________________ Current year 2007 _____________________________________________________________ Current Exp. Modifier: ____________ Assigned Risk Pool: Y N Expiration Date: ____________ Provide current and prior year NCCI Experience Modification Rating Worksheets. Indicate N/A if you are currently not rated.
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