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WORKERS COMPENSATION INSURANCE APPLICATION

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					                                       WORKERS’ COMPENSATION INSURANCE APPLICATION
                                       tel (310) 796-9050 – fax (310) 796-9054 – CA License # 0G78192

BUSINESS PROFILE INFORMATION
Note: the fields below should reflect the BILLING information.
First name:
Last name:
Title / position:
Business name:
Street address:
Floor / suite number:
City:
State:
Zip code:
Phone number:
Fax number:
Any locations outside of the United States?                                                                                       Yes      No
                                      Less than 1.00    1.00 to 1.34                 1.35 to 1.50         1.51 to 1.79        1.80 or higher
* Experience Modification Factor:
                                      None/Unknown
* If your experience modification factor is 1.80 or higher, please call us before completing this application.

GENERAL INFORMATION
DBA (if applicable):
Names of all business owners (List first and last names):



Main e-mail address (enter NONE if none):
Description of operations:
(Provide a detailed description of operations, including information about special products or customers specific to the insured.)




SIC code:
Business hours (e.g., 8 a.m. to 5 p.m.):
Business website address:
                            Individual      Partnership           Corporation       Limited Liability Company
Legal Structure:
                            Limited Liability Partnership          Estate     Joint Venture     Not-for-Profit            Trustee          Other
If “Other” for legal structure, explain:



FEIN (sole proprietors enter SSN):
Year established:
Owner’s years of industry experience:
(Number of years you have been working in this
field, including work for other companies.)
Projected annual billings or sales:
Is this a franchised operation?                                                                                                      Yes      No
Any business locations open 24 hours a day?                                                                                          Yes      No
Is applicant engaged in any other type of business?                                                                                  Yes      No
                                       CB MALAGA INSURANCE SERVICES LLC

Ownership interest in another business?                                                                         Yes     No
If yes, respond to the following:
     Provide name, operations, relationship, and ownership percentage:



     Is the risk this application is being completed for operating under the same entity name/FEIN as
     this other business ? Yes No
Any bankruptcies, tax or credit liens against this business in the last five (5) years?                         Yes     No
If yes, respond to the following:
     Explain:



Name of the individual to be contacted for a loss control survey:
Phone number of the individual to be contacted for a loss control survey:
Any insurers you would not like a quote from?                                                                   Yes     No
If yes, respond to the following:
     Insurer names:




OWNERS, PARTNERS, CORPORATE OFFICERS (INCLUDED/EXCLUDED)
Enter the total number of owners, partners, corporate officers:
Provide information for EACH partner and/or corporate officer associated with your business using the form below.
                              TITLE/                                                 INCL/    REMUNERATION/     CLASS   OWNER
       NAME                  POSITION                  DUTIES               STATE    EXCL        PAYROLL        CODE    SHIP%




Note: For additional entries, please use Appendix 1.

EMPLOYEE GENERAL QUESTIONS
Enter the total number of full-time employees (excluding owners, partners, corporate officers):
Lease employees to or from other employers?                                                                     Yes     No
If yes, respond to the following:
     Number of leased employees:

    Describe their duties:


    Does leasing organization provide Workers' Compensation coverage for these employees? Yes           No
    Obtain certificates of insurance from leasing organization? Yes No


                  WORKERS’ COMPENSATION INSURANCE APPLICATION - PAGE 2 OF 8
                                      CB MALAGA INSURANCE SERVICES LLC

Part-time or seasonal employees?                                                                                  Yes   No
If yes, respond to the following:
     Number of part-time and/or seasonal employees:

    Describe their duties:

     Is seasonal labor hired from temporary agencies? Yes    No
     Are the same employees called back each year? Yes       No
Use subcontractors?                                                                                               Yes   No
If yes, respond to the following:
     Type of work subcontractors perform:


    Percentage of work performed by subcontractors:           %

    Obtain certificates of insurance from leasing organization? Yes     No

    Require certificates of insurance from subcontractors? Yes     No
    If you do not require certificates of insurance, explain.


Any employees on payroll in OH, ND, WA, or WY?                                                                    Yes   No
(Note: In these five states only the state can sell workers' compensation coverage. However, these policies may
not cover employers liability. If you have employees in any of these states, verify exactly what your workers'
comp coverage includes)
If yes, respond to the following:
     Stop Gap coverage for your Employers’ Liability in these states? Yes No
Domestic employee turnover rate last year:                                                                        %
Domestic employee turnover rate two (2) years ago:                                                                %
Domestic employee turnover rate three (3) years ago:                                                              %
Foreign employee turnover rate last year:                                                                         %
Foreign employee turnover rate two (2) years ago:                                                                 %
Foreign employee turnover rate three (3) years ago:                                                               %
Maximum number of employees per shift at any one location:
Any business insurance policies declined, non-renewed, or cancelled in last three (3) years?                      Yes   No
If yes, respond to the following:

    Cancellation description (check only one):
      Prior WC carrier retired from market or insolvent
      Prior WC carrier stopped writing class of business
      Agent no longer represents prior carrier
      Other carrier “class of business” appetite
      New business declination – Carrier’s “years-in-business” requirement
      Billing dispute ended in cancellation
      Non-pay cancellation – 1 occurrence in last three years
      Moved coverage – Let policy cancel for non-pay to avoid short rate penalty
      Other:

    Names of insurance companies:




                  WORKERS’ COMPENSATION INSURANCE APPLICATION - PAGE 3 OF 8
                                       CB MALAGA INSURANCE SERVICES LLC

EMPLOYEE INFORMATION
If you employ workers in more than one state, provide information for workers in each state individually.
Provide information for EACH worker type/class to be covered under this policy.
                                        NUMBER OF EMPLOYEES                           ESTIMATED ANNUAL PAYROLL/PAYMENT TO
                          OFFICERS/     FULL TIME  PART TIME                                       OFFICERS/      EMPLOYEES
   CLASS                   OWNER/       (EXCLUDING     (EXCLUDING                                   OWNER/        (EXCLUDING
   CODE         STATE     PARTNERS       OFFICERS)      OFFICERS)    SEASONAL      CONTRACTORS     PARTNERS        OFFICERS)




Note: For additional entries, please use Appendix 2.

ADDITIONAL LOCATION INFORMATION
Enter a short description for this Location (e.g. Office, Warehouse):
Business location:                                                        Home         Lease   Own
Street address:
Floor / suite number:
City:
State:
Zip code:
Annual revenue earned at this location (%):                                            %
Provide the number of employees at this location that fit the             Full-time:
following types (excluding partners/corporate officers):
                                                                          Part-time:

                                                                          Seasonal:
Note: For additional entries, please use Appendix 3.

ADDITIONAL INFORMATION
Do you currently have a Workers’ Compensation Policy?                                                           Yes     No
If yes, respond to the following:

    Enter name of current insurance company:

    Type of insurance company (select one):
      Insurance co. with Best’s rating of A or higher               State fund
      Insurance co. with Best’s rating lower than A                 Assigned risk plan
      Risk retention group                                          Other (please describe):
      Self insurance fund

    Enter Policy Number:

    Limits (select only one):
      $100,000        $500,000        $1,000,000         Other (Enter):

    Effective date (MM/DD/YYYY):                           Expiration date (MM/DD/YYYY):

    Annual premium: $

If no, respond to the following:
     Requested effective date for New Policy (MM/DD/YYYY):

                  WORKERS’ COMPENSATION INSURANCE APPLICATION - PAGE 4 OF 8
                                         CB MALAGA INSURANCE SERVICES LLC
Do you have an “experience modification factor”?                                                                              Yes   No
If yes, respond to the following:
     Enter your exact experience modification factor:

    Bureau ID number:

Enter your loss ratio (if available):                                                                                                %
Provide group transportation to 6 or more employees in a single automobile?                                                   Yes   No
Use volunteers or donated labor?                                                                                              Yes   No
(Most standard insurance policies cover only employees. If you use volunteers you may have a gap in coverage.)
If yes, respond to the following:
     Number of volunteers:
     Describe duties:


     Is this a non-profit organization? Yes     No
     Is the intent to cover the volunteers? Yes    No
Labor interchange with any other business / subsidiary?                                                                       Yes   No
Any employees exposed to chemicals?                                                                                           Yes   No
If yes, respond to the following:
     Describe:



Any employees exposed to carcinogens?                                                                                         Yes   No
If yes, respond to the following:
     Describe:



Any past, present, or discontinued operations involving storing, treating, discharging, applying, disposing, or               Yes   No
transporting hazardous material (e.g., landfills, asbestos, wastes, fuel tanks, etc)?
If yes, respond to the following:
     Explain:


Employees do heavy manual lifting?                                                                                            Yes   No
If yes, respond to the following:
     Describe (include maximum weight of items lifted):


A subsidiary or own any subsidiaries?                                                                                         Yes   No
If yes, respond to the following:
     Describe nature of entity and any coverage details currently in place:



Employees work underground?                                                                                                   Yes   No
If yes, respond to the following:
     Describe:
    (Include details about your employees' specific activities, where the work is done, how far underground or above ground
    your employees work and how often your employees perform this kind of work.)




                   WORKERS’ COMPENSATION INSURANCE APPLICATION - PAGE 5 OF 8
                                          CB MALAGA INSURANCE SERVICES LLC
Any outside salespeople, delivery drivers or employees that drive on a daily basis?                                   Yes   No
If yes, respond to the following:
     Provide details:



Employees work on barges, vessels, docks, or bridges over water?                                                      Yes   No
If yes, respond to the following:
     Describe:
    (Include details about your employees' specific activities, where the work is done and how often your employees
    perform this kind of work.)




Employees travel by car for business purposes? (Excluding to and from work.)                                          Yes   No
If yes, respond to the following:
     Employees’ names and driver’s license numbers:



Employees travel outside the country for business purposes?                                                           Yes   No
If yes, respond to the following:
     Number of employees who travel outside the U.S.:

    List countries traveled to:

    Average number of trips taken annually:

    Average duration of each trip (in days)?

     Include foreign voluntary coverage? Yes    No
     Include repatriation coverage? Yes   No
     Include endemic disease coverage? Yes     No
Employee health plan provided?                                                                                        Yes   No
If yes, respond to the following:
     What percentage of employees participate in the health plan?             %
Any employees predominantly work at home?                                                                             Yes   No
Formal safety program at all locations?                                                                               Yes   No
(A good safety program can prevent accidents and help reduce your insurance costs.)
If yes, respond to the following:
     Describe (including lifting techniques, robbery training, production equipment maintenance, handling of
     animals, if applicable):



Any employees under 16 or over 60 years of age?                                                                       Yes   No
If yes, respond to the following:
     Provide name(s), age(s) and responsibilities/position(s):



Any employees have physical handicaps?                                                                                Yes   No
Employee workstations ergonomically designed at all locations?                                                        Yes   No
If no, respond to the following:
     Explain:




                    WORKERS’ COMPENSATION INSURANCE APPLICATION - PAGE 6 OF 8
                                          CB MALAGA INSURANCE SERVICES LLC

Established hiring practices including physicals, drug screening, application and reference checks?              Yes   No
Employees provided with training/education on ergonomic issues?                                                  Yes   No
If no, respond to the following:
     Explain:



Physicals required after offers of employment are made?                                                          Yes   No
Is there a return to work program in place?                                                                      Yes   No
Any workers’ compensation losses in the last five (5) years?                                                     Yes   No
If yes, provide information for EACH loss on the form in Appendix4 .
Any employees work ME, MN, NJ, NM, NY, or RI?                                                                    Yes   No
If yes, respond to the following:
     Enter the two-letter state abbreviation for states in which you have employees (i.e., ME, MN, NJ, NM, NY,
     RI). If more than one state, separate with a comma.



    Enter state unemployment ID for the states listed above. If more than one state, separate with a comma and
    list them in the same order as states entered above.



Own, lease, hire or operate aircraft?                                                                            Yes   No
If yes, respond to the following:
     Explain:



Own, lease, hire or operate watercraft?                                                                          Yes   No
Employees travel out of state?                                                                                   Yes   No
If yes, respond to the following:

    Percentage of workforce that travels out of state or travel requires overnight stays:   %

    Average number of trips per month?

    States of travel:

    Average duration (in days) of each trip?

     Do 5 or more employees ever travel together? Yes    No
Sponsor athletic teams?                                                                                          Yes   No
Any undisputed and unpaid workers’ compensation premium due from you (or any commonly managed or                 Yes   No
owned enterprises)?
If yes, respond to the following:
     Explain and identify named insured(s) and policy number(s) involved:



Select requested limits for Employers’ Liability Coverage (select one):

       $100,000 / $500,000 / $100,000
       $500,000 / $500,000 / $500,000
       $1,000,000 / $1,000,000 / $1,000,000
       $2,000,000 / $2,000,000 / $2,000,000



                   WORKERS’ COMPENSATION INSURANCE APPLICATION - PAGE 7 OF 8
                                       CB MALAGA INSURANCE SERVICES LLC

Additional comments:




FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or submits a claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Completion of this application does not bind coverage. Applicant’s acceptance of a company’s quotation, if such quotation is issued, is
required prior to binding coverage and policy issuance. CB Malaga Insurance Services LLC may not be able to obtain quotation from
any insurance company on behalf of the Applicant.

Depending on the type of Applicant’s business, CB Malaga Insurance Services LLC may require additional information which is not
contained in this Application.

All information provided in this Application is confidential and will only be used for the purpose of obtaining insurance quotes from
insurance companies. We will not sell or share your information with any other party.

The undersigned applicant further declares that he or she has read and understands the entire application including the applicable fraud
warning and that the statements set forth in this application are true and complete.

Applicant’s Name                                                   Signature


Title                                                              Date



Application must be signed by an owner, officer, partner or principal of the Applicant.




Please complete and sign this application and return to us:

         By email (scan of application) at info cbmalagains.com

         Or by fax at (310) 796-9054




                   WORKERS’ COMPENSATION INSURANCE APPLICATION - PAGE 8 OF 8
                                     CB MALAGA INSURANCE SERVICES LLC

                                                        APPENDIX 1


OWNERS, PARTNERS, CORPORATE OFFICERS (INCLUDED/EXCLUDED)
Total number of owners, partners, corporate officers:
Provide information for EACH partner and/or corporate officer associated with your business using the form below.
                             TITLE/                                               INCL/   REMUNERATION/         CLASS   OWNER
       NAME                 POSITION                 DUTIES             STATE     EXCL       PAYROLL            CODE    SHIP%




                           WORKERS’ COMPENSATION INSURANCE APPLICATION
                                      CB MALAGA INSURANCE SERVICES LLC

                                                          APPENDIX 2


EMPLOYEE INFORMATION
If you employ workers in more than one state, provide information for workers in each state individually.
Provide information for EACH worker type/class to be covered under this policy.
                                       NUMBER OF EMPLOYEES                        ESTIMATED ANNUAL PAYROLL/PAYMENT TO
                          OFFICERS/    FULL TIME  PART TIME                                    OFFICERS/      EMPLOYEES
  CLASS                    OWNER/      (EXCLUDING   (EXCLUDING                                  OWNER/        (EXCLUDING
  CODE         STATE      PARTNERS      OFFICERS)    OFFICERS)    SEASONAL     CONTRACTORS     PARTNERS        OFFICERS)




                            WORKERS’ COMPENSATION INSURANCE APPLICATION
                                        CB MALAGA INSURANCE SERVICES LLC

                                                            APPENDIX 3
                                                                                                   PAGE __ OF __

ADDITIONAL LOCATION INFORMATION
Enter a short description for this location (e.g. Office, Warehouse):
Business location:                                                      Home         Lease   Own
Street address:
Floor / suite number:
City:
State:
Zip code:
Annual revenue earned at this location (%):                                          %
Provide the number of employees at this location that fit the           Full-time:
following types (excluding partners/corporate officers):
                                                                        Part-time:

                                                                        Seasonal:

ADDITIONAL LOCATION INFORMATION
Enter a short description for this location (e.g. Office, Warehouse):
Business location:                                                      Home         Lease   Own
Street address:
Floor / suite number:
City:
State:
Zip code:
Annual revenue earned at this location (%):                                          %
Provide the number of employees at this location that fit the           Full-time:
following types (excluding partners/corporate officers):
                                                                        Part-time:

                                                                        Seasonal:

ADDITIONAL LOCATION INFORMATION
Enter a short description for this location (e.g. Office, Warehouse):
Business location:                                                      Home         Lease   Own
Street address:
Floor / suite number:
City:
State:
Zip code:
Annual revenue earned at this location (%):                                          %
Provide the number of employees at this location that fit the           Full-time:
following types (excluding partners/corporate officers):
                                                                        Part-time:

                                                                        Seasonal:



                             WORKERS’ COMPENSATION INSURANCE APPLICATION
                                        CB MALAGA INSURANCE SERVICES LLC

                                                             APPENDIX 4
                                                                                                                        PAGE __ OF __


WORKERS’ COMPENSATION LOSSES IN THE LAST FIVE (5) YEARS
Provide information for EACH loss on a separate page.
Enter a short description for this Loss (e.g. Loss 1, Loss 2):
Date of loss (MM/DD/YYYY):
Type of loss:                                                     Medical only          Indemnity All Other
Loss description (select only one):                                 Burn or Scald – Contact with hot object, fire, steam or hot fluids
                                                                    Burn or Scald – Electrical Current
                                                                    Burn or Scald – All Other
                                                                    Caught in, under, or between machine or object
                                                                    Caught in, under, or between collapsing material
                                                                    Caught in, under, or between – All Other
                                                                    Cut, puncture, scrape injury by hand tool or power tool
                                                                    Cut, puncture, scrape injury by object being lifted or handled
                                                                    Cut, puncture, scrape injury – All Other
                                                                    Fall, Slip or Trip from different level
                                                                    Fall, Slip or Trip from ladder, scaffolding or stairs
                                                                    Fall, Slip or Trip – All Other
                                                                    Motor Vehicle – Collision with another vehicle or upset vehicle
                                                                    Motor Vehicle – Collision with fixed object
                                                                    Motor Vehicle – All Other
                                                                    Strain or injury by lifting, carrying, reaching, pushing, pulling
                                                                    Strain or injury by continual noise
                                                                    Strain or injury by repetitive motion
                                                                    Strain or injury – All Other
                                                                    Striking against or stepping on object being lifted or handled
                                                                    Striking against or stepping on sharp object or machine moving part
                                                                    Striking against or stepping on – All Other
                                                                    Struck or injured by falling or flying object
                                                                    Struck or injured by fellow worker or patient
                                                                    Struck or injured by machine in use
                                                                    Struck or injured by motor vehicle
                                                                    Struck or injured – All Other
                                                                    Miscellaneous – Foreign object in eye or other body part
                                                                    Miscellaneous – Injury caused by person in act of a crime or assault
                                                                    Miscellaneous – All Other
Date claim was filed (MM/DD/YYYY):
Amount paid:                                                      $
Amount reserved:                                                  $
Current claim status:                                             Closed         Open
Valuation date of this loss information (MM/DD/YYYY):




                             WORKERS’ COMPENSATION INSURANCE APPLICATION

				
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