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Sample Workers Compensation Submission
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Additional Information
Premium Reduction Tips
Contents
Application
Company Narrative
Named Insured List
Location List
Payrolls
Loss Summary
Large Loss Descriptions
Loss Runs
Experience Modification Worksh
heet
Other Item to Include
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2
ACORD ™
Phone
AGENCY
Date (MM/DD/YYYY)
WORKERS COMPENSATION APPLICATION
Company
Underwriter
EMAIL
Applicant Name
Internet Address
ADDRESS:
ABC Manufacturing
(A/C, No, Ext):
FAX
(A/C, No):
www.abcmanufacturing.com
--- See Named Insureds Section for All Applicable
MAILING
ADDRESS
123 S Main St, #101
San Diego CA 92101
(including
ZIP code)
CODE:
SIC
INDIVIDUAL
1962
3089
PARTNERSHIP
CORPORATION
LLC
SUBCHAPTER "S" CORP
OTHER
CREDIT
SUB CODE:
ID NUMBER:
BUREAU NAME:
AGENCY CUSTOMER ID
STATUS OF SUBMISSION
X QUOTE
X
YRS IN BUS
FEDERAL EMPLOYER ID NUMBER
NCCI ID NUMBER
95-1234567
N/A
OTHER RATING BUREAU ID OR STATE
EMPLOYER REGISTRATION NUMBER
1234567 (WCIRB)
BILLING/AUDIT INFORMATION
ISSUE POLICY
BILLING PLAN
AUDIT
PAYMENT PLAN
AT EXPIRATION
MONTHLY
SEMI-ANNUAL
OTHER:
X
OFFER
SEMI-ANNUAL
OTHER:
QUARTERLY
% DOWN:
QUARTERLY
BOUND (Give date and/or attach copy)
AGENCY BILL
ANNUAL
ASSIGNED RISK (Attach ACORD 133)
DIRECT BILL
LOCATIONS
STREET, CITY, COUNTY, STATE, ZIP CODE
#
1 123 S Main St # 101 San Diego CA 92101
2
3
POLICY INFORMATION
PROPOSED EFF DATE
PROPOSED EXP DATE
NORMAL ANNIVERSARY RATING DATE
2/3/2007
2/3/2008
2/3/2007
PART 1 - WORKERS
COMPENSATION (States)
CA
0
PART 2 - EMPLOYER'S LIABILITY
$
EACH ACCIDENT
$
1,000,000
DISEASE - POLICY LIMIT
$
1,000,000
DISEASE - EACH EMPLOYEE
DIVIDEND PLAN/SAFETY GROUP
NON-PARTICIPATING
PART 3 - OTHER STATES INS
1,000,000
RETRO PLAN
PARTICIPATING
DEDUCTIBLES
All Other States WC
Coverage
Endorsement
AMOUNT/%
OTHER COVERAGES
MANAGED CARE
OPTION
MEDICAL
U.S.L. & H.
INDEMNITY
VOLUNTARY COMP
ENTIRE CLAIM
FOREIGN COV
ADDITIONAL COMPANY INFORMATION
RATING INFORMATION
STATE
LOC
# EMPLOYEES
DESCR
CODE
CLASS CODE
CATEGORIES, DUTIES, CLASSIFICATIONS
FULL TIME
PART
TIME
ESTIMATED
ANNUAL
ESTIMATED
RATE
ANNUAL PREMIUM
REMUNERATION
***See Attached Payrolls Spreadsheet***
SPECIFY ADDITIONAL COVERAGES/ENDORSEMENTS
FACTOR
All States WC Coverage Endorsement
FACTORED PREMIUM
TOTAL
$
INCREASED LIMITS
$
DEDUCTIBLE
$
$
EXPERIENCE MODIFICATION
LOSS CONSTANT
Extended Notice of Cancellation: 90 Days
1.27
$
N/A
$
ASSIGNED RISK SURCHARGE
$
ARAP
$
$
PREMIUM DISCOUNT
$
EXPENSE CONSTANT
N/A
$
TOTAL EST ANNUAL PREMIUM
N/A
$
$
MINIMUM PREMIUM
ACORD 130 (2003/10)
$
DEPOSIT PREMIUM
$
PLEASE COMPLETE REVERSE SIDE
© ACORD CORPORATION 1980
3
INDIVIDUALS INCLUDED/EXCLUDED
PARTNERS, OFFICERS, RELATIVES TO BE INCLUDED OR EXCLUDED (Remuneration to be included must be part of rating information section.)
NAME
#
DATE OF BIRTH
TITLE/ RELATIONSHIP
OWNER SHIP %
DUTIES
INC/EXC
CLASS CODE
1 John Doe
Pres/CEO
50
Excl
8810
2 Jane Doe
CFO
50
Excl
8810
REMUNERATION
PRIOR CARRIER INFORMATION/LOSS HISTORY
PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS
YEAR
CARRIER & POLICY NUMBER
CO:
POL #:
X
ANNUAL PREMIUM
MOD
# CLAIMS
LOSS RUN ATTACHED
AMOUNT PAID
RESERVE
***See Attached Loss
Summary***
CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS
GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS: MANUFACTURING - RAW MATERIALS, PROCESSES, PRODUCT, EQUIPMENT. CONTRACTOR - TYPE OF WORK,
SUB-CONTRACTS. MERCANTILE - MERCHANDISE, CUSTOMERS, DELIVERIES. SERVICE - TYPE, LOCATION. FARM - ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS.
Injection Molded Plastics --- See Narrative of Operations for more details
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES
YES NO
1 DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT?
X
EXPLAIN ALL "YES" RESPONSES
YES NO
16 ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
X
DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING,
2 TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF
HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)
X
3 ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
X
19 ARE EMPLOYEE HEALTH PLANS PROVIDED?
4 ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
X
20 IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?
X
5 IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
X
21 DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
X
17 ANY OTHER INSURANCE WITH THIS INSURER?
18
ANY PRIOR COVERAGE DECLINED/
CANCELLED/NON-RENEWED (Last 3 years)?
NOT APPLICABLE IN MO
X
X
6 ARE SUB-CONTRACTORS USED? (IF YES, GIVE % OF WORK SUBCONTRACTED)
X
22 DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?
X
7 ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.?
X
23 ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS?
X
8 IS A WRITTEN SAFETY PROGRAM IN OPERATION?
X
9 ANY GROUP TRANSPORTATION PROVIDED?
24
X
10 ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
X
11 ANY SEASONAL EMPLOYEES?
X
12 IS THERE ANY VOLUNTEER OR DONATED LABOR?
X
13 ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
X
14 DO EMPLOYEES TRAVEL OUT OF STATE?
X
15 ARE ATHLETIC TEAMS SPONSORED?
X
ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR
OWNED ENTERPRISES? IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S)
INSPECTION
PHONE:
(619) 555-1234
NAME:
John Doe
ACCTNG
RECORD
PHONE:
(619) 555-1234
NAME:
Jane Doe
CLAIMS
INFO
PHONE:
(619) 555-1234
NAME:
Janie Doe
X
APPLICABLE IN TENNESSEE: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS COMPENSATION TRANSACTION FOR THE
PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR
STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES.
(Not applicable in CO, HI, NE, OH, OK, OR, TN, or VT; in DC, LA, ME, and VA, insurance benefits may also be denied)
REMARKS
1: See attached Aircraft or Watercraft details 6: 10%: Regular operations - if don’t have capacity 10: 4 employees over 60
APPLICANT'S SIGNATURE
DATE
PRODUCER'S SIGNATURE
NATIONAL PRODUCER NUMBER
ACORD 130 (2003/10)
4
ABC Manufacturing
Narrative of Operations
ABC Manufacturing is a successful Injection Molding Plastics business founded
in 1962. They are based out of San Diego CA, and are looking for quotes on
their Workers' Compensation effective 2/3/07.
This Narrative will give a lot of details of their operations, especially in relation to
their insurance programs. More information about the company in general can
be found on their website: www.abcmanufacturing.com
Operations
ABC runs its operations 18 hours a day, 6 days a week. Their primary products
are pool supplies and collapsible produce crates. All products can be
customized to any customer’s needs. Until a couple years ago, 100% of their
work was custom molding. More than 40% of operations are now completely
automated, and require no more than the push of a button by employees.
They use enormous machines for this automated process, and the expense of
these machines is actually one of their competitive advantages. Access to the
machines is prevented by cages, which are accessible for authorized employees
to make adjustments to the machines.
Ownership Involvement
The owners of ABC Manufacturing are still active in the management of the
company. They manage the company on a daily basis, and are still the voice
and face of their company. The owners understand that Workers' Comp is a
major part of their budget and are willing to take whatever steps are necessary to
improve their already good programs and practices. The owners even participate
in the Workers Comp program in the following areas: Attend Safety Meetings.
Employee Counts
Approximate employee counts by job type:
Total # of
Description of job
Employees
21 (4 shifts)
Automated Machines Operations
(broken up
further below)
1 (of 21)
Finish products by taking away from machine, scanning for
errors, and shrink wrapping. Uses a forklift for lifting
16 (of 21)
Techs: simply watch machines and controls to make sure it is
5
4 (of 21)
105 (3 shifts)
(broken up
further below)
6 (of 105)
6 (of 105)
2 (of 105)
93 (of 105)
9
15
5
8
8
operating properly
Material transport people: use forklifts to supply stations
Custom Plastic Machine Operations
Flamers: employees will use open flames from small 5-gallon
propane tanks to melt sharp edges, these ee’s receive
extensive training, and open flame work is less than 15% of
their time worked.
Assemblers: install parts. Example: install on metal frame
Sewing: operate manual sewing machines. Put fabric over a
plastic shell or pull fabric over a part and sew end shut
Basic machine operators: Use trim knives during work. Lift up to
40 pounds (turn down customers that want heavier items).
Non-Operations Employees
Maintenance department: basically machine mechanics. Some
lifting as required. Minor exposure to heat, hydraulic pressure,
limited welding, grinding, drill presses. 7 have been at ABC for
more than 10 years.
Office Employees
Tool Shop: machine tools with a lathe and drills. Move molds
with forklifts. Primarily “wrench work”
Shipping: forklifts loading and unloading of trucks
QA: no real physical hazards, use precision measuring tools to
make sure product meets specs.
Comparison With Industry Peers
ABC Manufacturing knows that insurance companies will base their premiums on
both the company's own specific loss history, as well as expected losses for their
industry type (by class codes). Because of this, they would like to emphasize
that they strongly consider themselves to be a much better risk than their industry
peers, and should therefore have lower expected losses. Reasons that they are
better include: Better Safety Programs, Experienced Supervisors, Experienced
Ownership, More Ownership Involvement, Longer-Term Employees, Lower
Turnover, Employees' Work is Safer than industry standard, Less Driving
Exposure than industry standard, Better or Newer Equipment/Machinery, Size
Advantage (economies of scale), Culture of respect and trust within the company
gets the job done right, among others.
Hiring Procedures
ABC Manufacturing has the following percentages on how they find new
employees: 30% referrals by employees, 70% newspaper ads.
6
ABC Manufacturing is a company that is aware of the importance of its hiring
practices and procedures, and how those can directly affect Workers'
Compensation claims experience and premiums. Because of this, they have
instituted the following hiring procedures for all new employees: Written
Application; Formal Interview with Jeanette Garcia, HR Manager; Written Job
Descriptions; Written Personnel Procedures; Reference Checks for those
prospects they feel they need them on; Documenting all personnel records for
pre-existing injuries; New Employee Training/Orientation; among others.
More details will be given on the following aspects of the company's Hiring
Procedures: New Employee Training/Orientation,
New Employee Training/Orientation
Every new hire at ABC Manufacturing will go through their employee training and
orientation program. ABC Manufacturing wants to make sure all employees are
fully prepared to safely do their jobs before letting them work without oversight.
Employee Benefits
In order to improve both employee morale and employee retention, ABC
Manufacturing has given its workers the following benefits: Group Medical
Benefits (more details later), a 401(k) or similar Retirement Plan, Dental,
Production (Meeting Quota) Bonuses, Life Insurance Policy for employees,
Disability Insurance Policy for employees, Paid Holidays: 6 per year, Paid Sick
Days: up to 5 (after 1 year) per year, Paid Vacations, and other benefits as well.
Group Medical Plan
The employees of ABC Manufacturing are eligible to join the company's Group
Medical Plan after 90 days of service. Currently, all employees, regardless of
employee level, are eligible for the plan. 80% of premiums are paid by the
company. About 60% of eligible employees are on the company Group Medical
Plan. Of the employees not on the company Group Medical Plan, ABC
Manufacturing thinks some may have medical coverage on an outside policy,
approximately: 10% Spouse's plan, 20% All Other. ABC Manufacturing is
aware that employees who have medical coverage are much less likely to file
fraudulent claims, especially claims that are not work-related but are said to be
so the employee has medical coverage somewhere. For this reason, the
company is always striving to strengthen its Group Medical Plan and any savings
on Workers' Comp would greatly help.
Employee Morale
Because of the excellent working environment and conditions at ABC
Manufacturing, company employees have excellent employee morale. Reasons
7
for the higher morale include: Responsive Supervisors, Responsive Ownership,
Long-Term Employees, Family Atmosphere, Christmas Bonus, Job Security, Biweekly "Continual Improvement Process" meetings, , and other reasons as noted
elsewhere in this Narrative. Studies have shown that happy workers are much
less likely to file Workers' Comp claims, and when they do they are usually
smaller in dollar amounts and much less likely to be fraudulent.
Employee Turnover
ABC Manufacturing has approximately the following Turnover percentages: 1%
for the current year, 1% for the first prior year, and 1% for the second prior year.
It also is very important to note that the company is successful in retaining
employees once they get past the first couple months. Approximately 99% of
employees have been with the company over one year, 95% over two years,
90% over three years, 75% over five years, 50% over ten years. Studies have
shown that employees in their first six months on the job are much more likely to
be injured than seasoned employees. ABC Manufacturing is aware that hiring,
training, and keeping good workers is one of the best ways to keep Workers'
Comp costs low.
Workers' Comp Claims Procedure
ABC Manufacturing has the following set of standard procedures for reporting
Workers' Comp claims: Injured workers are immediately sent to Concentra, the
company's Designated Medical Provider (more details on them later). All injured
employees will immediately have a drug test done. The person in charge of
claims at ABC Manufacturing fills out a formal, written claim/accident report for
each incident. There is an immediate internal Accident Investigation (more
details on this later). All claims are then submitted to the insurance carrier on the
applicable forms. 90 percent of claims are reported within 24 hours, and 100
percent within 48 hours. ABC Manufacturing is aware of the importance of
timeliness in reporting claims, especially in regards to keeping total claims costs
in control. ABC Manufacturing has all injured employees entered into their
Medical Provider Network (MPN), which they first entered in Feb. 2005. There
are no employees that have pre-designated their own physician outside of the
MPN network.
Designated Medical Provider
As stated before, ABC Manufacturing has chosen to work closely with Concentra
as their Designated Medical Provider. Concentra is a specific clinic that ABC
Manufacturing has built a strong, mutually beneficial relationship with. Concentra
is aware of the operations, safety program, and overall needs of ABC
Manufacturing. They work with the company to determine the best course of
action for each injured employee, and will help point out any possible fraud.
8
Accident Investigation Procedures
Every Workers' Comp claim at ABC Manufacturing will have an immediate
Accident Investigation done. This will be done by the injured employee's
supervisor(s). Standard investigation procedures include the following: Interview
of the injured employee; Witness interviews; and any other applicable/needed
investigations.
Claims Follow-up
The claims personnel of ABC Manufacturing will work closely with both the
Workers' Compensation carrier and the clinic/physician in care of the injured
employee to determine the best course of action at all times. All injured
employees who are out on indemnity leave will be followed up with at least every
other week. This follow-up is done by the HR department of the company. All
follow-ups are positive and letting the employee know they are wanted back as
soon as they are healthy. This is important because studies have shown that
follow-up by the injured employee's co-workers can drastically reduce claims
values on an indemnity claim.
Return to Work Program
ABC Manufacturing knows the importance of getting injured workers back to
work as soon as possible. They know that offering 'restricted duty' positions
through a Return To Work (RTW) program can drastically reduce the total claim
values of indemnity claims. To this end, the company has instituted a formal
RTW program intended to offer a position to any injured employee. They try to
place these people in 'boring' positions that will make them want to return to
normal duties as soon as possible.
Vehicle/Driving Exposures
ABC Manufacturing does not have any company vehicles, and therefore does not
have any vehicle or driving exposures for its employees under normal operations
of the business.
Condition of Equipment/Premises
The overall condition of premises at ABC Manufacturing is excellent. The
housekeeping/cleanliness of ABC Manufacturing is excellent. All
equipment/machinery at ABC Manufacturing is new. All equipment used is
standard for the industry. All machinery has full and proper guards in place at all
times. All machine operators use proper Lock Out/Tag Out procedures. There is
a full inspection and maintenance program in place for all machinery.
Inspections are done monthly.
9
Lifting Exposures
The maximum amount of weight that any employee will lift by themselves is 40
pounds, which is the amount usually considered the most an average person can
easily carry without risk of injury. About 100 employees are exposed to lifting this
amount. The average employee will lift at most per industry standard. The
company has a formal, written safe lifting program that lets employees know
required safe lifting procedures. Any large, awkward, heavy, or unusually
shaped objects are required to be lifted by teams of at least two people. ABC
Manufacturing has 14 forklifts that greatly assist in keeping the maximum lift by
any one person very low. All forklift operators are certified on their machines.
Employees use pallet jacks or hand carts when possible. Employee workspaces
are designed to minimize the lifting/moving of objects as much as possible.
Employees are provided with and encouraged to take adequate rest time
between lifts. Back belts are recommended while lifting. The company has
Mechanical Lifting Devices to further aid in lowering the max amount employees
lift: Cranes and Hoists.
Slip/Fall Exposures
ABC Manufacturing has formal Slip/Fall training and/or programs. Slip/Fall
Safety Procedures include: Cleaning all spills immediately; Requiring basic
housekeeping such as closing all drawers and hiding of all wiring; Marking
walking areas in warehouse/storage room/etc.; Barricading/covering all changes
in floor level; Keeping all areas of the premises well-lit.
Employee Age
ABC Manufacturing currently has only about 4 (2 office, 2 floor) employees over
60 years old, and they do not have any employees under 16 years old. This is
significant because these age groups typically have higher claims frequency and
severity, usually attributed to either less work-related or 'real world' experience
(for those under 16), or diminished capabilities (for those over 60). The
company is aware of the problems with hiring older workers and does everything
it can to mitigate or lessen their exposure to injury. Because the company does
not have any of the younger employees, they are a better Workers' Comp risk.
Safety Program
There are many parts to the Safety Program of ABC Manufacturing. The
program is under the stewardship of Pat Brady, HR. Because the company is
dedicated to creating a safe work environment, they have all of the following
procedures currently in place:
ABC Manufacturing has their safety program formalized and written for all
employees to access. They have an active Injury and Illness Protection Program
10
(IIPP). The company pays for Hazard Identification training for all Floor
Employees. They have a Hazardous Materials Communication Program in
place. Company Supervisors are trained Safety Education monthly. The
company conducts periodic Fire and Emergency evacuation drills. The company
has progressive discipline for safety violations. The company has Violence
Intervention Program in place
More details will be given on the following aspects of the company's Safety
Program: Safety Meetings, Safety Committee, Safety Director/Risk Manager,
Safety Inspections, Safety Incentive Program, Accountability for Safety, Personal
Protective Equipment (PPE).
Safety Director/Risk Manager
ABC Manufacturing has a Safety Director. Their Safety Director's name is John
Doe and this person has 25 years of experience in Safety. The position is Part
Time, with John Doe devoting approximately 20% of work hours to Safety issues.
Safety Meetings
ABC Manufacturing holds monthly Safety Meetings as a way to keep employees,
supervisors, and managers continuously talking and thinking about Safety.
Team members present in these meetings will discuss how best to keep all
employees safe, and may draw on both outside sources and internal thoughts for
discussion topics. All Safety issues are communicated to employees by the
following method: email photos of hazards and remedies.
Safety Committee
ABC Manufacturing holds regular meetings with its Safety Committee. This
committee is a small group of representatives who determine the Safety goals,
rules, and regulations of the company. The Committee meets monthly.
Safety Inspections
There are regular inspections of all company premises. These thorough
inspections are done quarterly and are an integral part in ensuring all employees
and supervisors are both understanding and following all safety regulations.
Safety Incentive (Bonus) Program
ABC Manufacturing also has a Safety Incentive Program that they feel is an
important tool in keeping employees constantly aware of being safe by giving
them monetary or other rewards for staying safe. Many studies have shown that
Safety Incentive Programs can lower both claims frequency and claims severity
11
drastically. Here is how ABC Manufacturing operates their program: Safety
Bingo - Gross $300-$500 per paycheck available
Accountability for Safety
Supervisors/Foremen are held accountable for the Safety and Claims records of
the employees they oversee. The primary ways they are held accountable are
Peer pressure. The company believes that holding their supervisors accountable
is a crucial tool in having the Safety Program followed by all employees.
Employees who are doing the actual labor are held accountable for their own
Safety and Claims records. The primary ways they are held accountable are
discipline only. The company believes that holding both supervisors and
employees accountable is a crucial tool in having the Safety Program followed by
all employees.
Personal Protective Equipment (PPE)
The company strongly recommends or requires the use of Personal Protective
Equipment (PPE) at all appropriate times while working. Types of PPE used
include: Gloves (required), Goggles (required), Hearing Protection (required),
All employees are aware of the availability of PPE and the company rules
regarding its use, and the possible consequences of not using PPE.
Recap
ABC Manufacturing is a successful Injection Molding Plastics business based out
of San Diego, CA. The company is devoted to continuing its excellence in all
areas of their business, with a recent emphasis on lowering Workers'
Compensation costs. To this end, they have strengthened their Safety/Loss
Control, Claims Procedures, Hiring Procedures, and many other areas. They are
excited about finding ways to continue this important trend and welcome any
recommendations from carriers or brokers that will make their program even
better still. Overall, ABC Manufacturing is an excellent company that deserves
an excellent insurance program.
12
Insert photos on the following pages, including photos of:
1. Operations, preferably in order of manufacture, starting with receiving of
raw materials, through each stage of manufacturing, on through to
shipping.
2. Employees, as they actually perform their duties, in order to give
underwriters a good sense of the actual work and any hazards, and how
the hazards are controlled. Show equipment guards, safety equipment,
etc.
3. Key Personnel. Pictures of key staff members give underwriters a sense
of the company.
13
ABC Manufacturing
Named Insureds
Named Insured
ABC Manufacturing, Inc.
ABC Mfg, Inc.
ABC Property Managers
ABC Plastics (DBA)
Primary Operations or each Named Insured
Injection Molded Plastics
Injection Molded Plastics
Owns the Building
N/A
FEIN
95-1234567
95-1234568
N/A
N/A
Type of Entity
Corporation
Corporation
Partnership
14
ABC Manufacturing
Loc #
List of Locations
Street Address
1 123 S Main St
Apt/
Suite
#
101
City
San Diego
State
CA
ZIP
92101
Construction
Year Built
Type
1978 Concrete Tilt-Up
Occupancy
Office/Operations
Hours of
Operation
Start To End
5am
To
11pm
# of
# of Days/
Shifts Week
2
6
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
15
ABC Manufacturing
Payrolls Sheet
Class
State Code
CA
4498
CA
8742
CA
8810
# of employees
Description
FT
/
PT
Plastics Injected Molded Products Mfg - N174
OC /
Salespersons - Outside
5
/
Clerical Office Employees - N O C
10
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Next Year's
Estimates
Current
Year
Payrolls
1st Prior 2nd Prior
Year
Year
3rd Prior
Year
4th Prior
Year
4,000,000
4,000,000
3,924,665
3,622,149
3,645,123
3,501,288
425,000
425,000
400,000
380,000
302,654
303,899
350,000
350,000
301,589
366,000
215,644
280,000
16
ABC Manufacturing
Workers' Compensation Loss Summary
Policy Period
/
2/3/2006
2/3/2007
/
2/3/2005
2/3/2006
/
2/3/2004
2/3/2005
/
2/3/2003
2/3/2004
/
2/3/2002
2/3/2003
/
2/3/2001
2/3/2002
/
1/0/1900
Insurance Carrier
Policy Number
Valuation
Date
Claim
Count
Reserves
Paid
Incurred
Republic Indemnity
1234567
12/1/2006
2
21,999
941
22,931
Republic Indemnity
1234567
12/1/2006
7
0
5,198
5,198
Republic Indemnity
1234567
12/1/2006
14
179,126
173,261
352,387
Republic Indemnity
1234567
12/1/2006
11
0
439,119
439,119
Republic Indemnity
1234567
12/1/2006
9
27,784
63,781
91,565
Republic Indemnity
1234567
12/1/2006
2
0
2,606
2,606
0
0
0
Please see Large Loss Descriptions document for details on large losses
17
ABC MANUFACTURING
Workers Compensation
Large Loss Descriptions (Over $25,000)
February 3, 2006-2007
NO CLAIMS OVER $25,000
February 3, 2005-2006
NO CLAIMS OVER $25,000
February 3, 2004-2005
December 5, 2004
Name Withdrawn
$51,360 (Open)
Mr. Withdrawn is a QA inspector. He injured himself while trying to repair a hot stamp
machine, asking an employee to try the button to see if it worked while he had his thumb
in the machine. This was an extremely stupid claim, from an employee who is never
authorized to work on the machines or even operate the machines. He was given
modified duty while he recovered, reprimanded, and is now back to work.
November 10, 2004
Name Withdrawn
$75,217 (Open)
Mr. Withdrawn was helping another worker unload a hopper and strained his shoulder.
The circumstances of this claim are unusual because ABC has people who are
specifically trained as materials handlers, and Mr. Withdrawn should not have been at
this station. He was hurt due to inexperience. This claim was litigated.
November 8, 2004
Name Withdrawn
$26,746 (Open)
Mr. Withdrawn claimed unspecific injuries to several body parts due to lifting. The claim
was highly suspicious and ABC fought it hard. There were no witnesses to the claim, and
he had access to a forklift at all times while at work. He has hired a lawyer.
April 19, 2004
Name Withdrawn
$32,169 (Closed)
Ms. Withdrawn claimed repetitive motion injuries to several body parts. This claim was
extremely suspicious, and ABC believes she tried to claim a fraudulent similar injury
shortly after the other two repetitive motion claims above. She actually claimed injury on
a day she was not even working, then changed her statement. She immediately hired a
lawyer in this claim.
April 15, 2004
Name Withdrawn
$88,645 (Open)
Ms. Withdrawn was a machine operator. She also claimed repetitive motion injuries to
her wrists and hands. This, however, appears to be a completely legitimate injury. She
hired a lawyer who bumped up the cost of the claim, but returned to work for ABC for a
while. She has since left the company but left on good terms.
18
April 5, 2004
Name Withdrawn
$68,404 (Open)
Ms. Withdrawn was a machine operator. She claimed elbow and forearm pain from
repetitive motion despite ABC’s practice of constantly having employees rotate jobs to
avoid repetitive motion injuries. She reported the injury several weeks after it occurred,
and said it was no big deal. She eventually quit for unknown reasons and then hired a
lawyer to make this claim more substantial.
February 3, 2003-2004
November 14, 2003
Name Withdrawn
$40,233 (Closed)
Ms. Withdrawn fractured her fingers in a slip and fall after stepping on a wooden pallet.
The claim was legitimate, but she immediately hired a lawyer and got her own doctor.
Both of these would be much less likely to occur in ABC’s current MPN. She left the
company after the accident and refused any RTW.
November 14, 2003
Name Withdrawn
$49,775 (Closed)
Mr. Withdrawn is a process tech. He was working on an elevated platform on an
injection molding machine. After he was finished, instead of taking the stairs down he
jumped down the three feet and injured his back. It was an extremely stupid injury and
against all regulations. ABC brought this up in safety meetings afterwards. There has
been no surgery but the claim is litigated.
October 14, 2003
Name Withdrawn
$24,692 (Closed)
Mr. Withdrawn was a shift supervisor. While walking in the production department he
slipped and fell, fracturing his left ankle. There was no hazard on the floor, he just
slipped. He never hired a lawyer and was helpful during the claim. He is now retired and
no longer works for ABC.
September 20, 2003
Name Withdrawn
$317,669 (Closed)
Mr. Withdrawn was a machine operator. He fractured his knee by slipping while
stepping on a box to crush it in the trash bin. This was a very unusual claim, but appears
to be completely legitimate. He had to have two surgeries on the knee, but never hired a
lawyer. Most of the claim is for medical expenses.
February 3, 2002-2003
May 5, 2002
Name Withdrawn
$60,684 (Open)
Mr. Withdrawn claimed injuries to his shoulder when he was stretch wrapping. It was an
extremely suspicious claim, and ABC’s accident investigation thinks the claim could
never have happened the way he described. They believe he got hurt at another job he
had, and filed claims at both places. He no longer works for ABC.
February 3, 2001-2002
NO CLAIMS OVER $25,000
19
Loss Runs
20
21
22
23
24
25
26
27
28
29
Other Items to Include in Application/Submission Package
(in electronic format if possible)
1. 5 Years of Policy Information for each Coverage.
(or Name of Insurer, Policy Number, & Policy Dates)
2.
3.
4.
5.
Copy of Safety Manual.
Copy of Employee Manual.
Copies of Brochures on the company.
List of Awards won by Company.
(Community Awards, Industry Awards, Charity)
6. Brief bios on top management.
7. Written Training Information.
8. Number of Employees by class code.
9. FEIN Number.
10. List of Named Insureds (& description of each).
11. Details on any Claims over $10,000. In value.
12. Procedures on Claims.
13. Historical Turnover, especially compared to your industry.
14. Health Insurance offered (& percentage of employees
participating in benefit plan).
15. Safety Procedures (meetings, topics, frequency).
16. Hiring Practices (screening, training, orientation, etc.).
17. Medical Provider (for W. C. claims).
18. Safety Incentive Plan Details (if any).
30