Please provide details for all of
your business operations.
Insurance History:
If Previous Insurance Lapsed, Why?
Years in Business:
Organization Type:
Please provide your FEIN #:
How Many Locations?
Are any locations outside of NJ?
-If so, please list each location & state:
Payroll Information:
Annual Payroll (All Locations):
Note: This figure is
for all payroll that would fit under your business description or primary
classification.
Clerical Only Payroll (If Any-All Locations):
Note: This figure is
for total payroll to employees whose duties are strictly & only clerical in
nature (i.e. Bookkeeper, File clerk, HR Administrator, Accounting Dept., Etc.).
Outside Sales Payroll (If Any-All Locations):
Note: This figure is
for total payroll for employees who are company sales representatives & have no
other duties.
Do officers/owners wish to elect coverage?
Note: Proprietor, Partnership or LLC Only
Number of Officers:
Officer's Annual Payroll:
Please provide a breakdown for all officer's payroll & their duties/job
description.
Limits Desired:
Underwriting Information:
Are you engaged in any other
type of business?
Do you lease employees
to/from other employers?
Own/operate or lease
aircraft/watercraft?
Any employee under 16 or
over 60?
Any group transportation
provided?
Any labor interchange with
any other business?
Any subcontractors used?
-If so, how much annually do you pay out to subcontractors who do
not provide evidence of workers compensation coverage & what type of work is
subcontracted out?
Are physicals required of
new employees?
Any part-time, seasonal,
volunteer or donated labor?
Please provide details for any questions which you answered YES:
Claims Information:
Current Experience Mod:
Any Claims within 3 Years:
If So, Describe (Include Date and Pay Out Amount):