For Office Use Only Date Submitted: Service Provider: Account Manager: Request for Proposal The following documents are required to receive preliminary pricing: Completed request for proposal form 36 months loss history (loss runs) from any carrier that provided worker’s compensation during that period Supplemental risk questionnaire Work comp experience mod worksheet Other: Choose one (if applicable) Other: Choose one (if applicable) Other: Choose one (if applicable) GENERAL BUSINESS INFORMATION Business name: FEIN#: DBA: Business type: Contact name: Contact position: Street address: Phone: City, state, zip: Years in business: Email: Web address: DETAILED DESCRIPTION OF BUSINESS ACTIVITIES Work Comp Payroll Estimated annual payroll: Current carrier: No. W-2 employees: Effective date: State unemployment rate (SUTA): Current experience modifier: Current payroll provider: 3 Years Historical Payroll & Premium No. locations receiving checks: Type of time and attendance: Year Payroll Premium Account manager comments (for office use only): 4FDVSF8PSL$PNQ %PZMF$BSMUPO4VJUF t Tampa, FL 3360 t www.TFDVSFXPSLDPNQ.com Page 1 / 4 Request for Proposal State WC Code FT # of EE PT Annual Gross Payroll for this Class Code Please group by state abbreviation if you conduct business in more than one state. *This document is for Human Resources Professionals only. Proposals expire after 30 days and all rates are subject to final underwriter approval. This is not an application for insurance or an approval for outsourcing services. This questionnaire represents the required information to obtain quotes. 4FDVSF8PSL$PNQ %PZMF$BSMUPO4VJUF t Tampa, FL 3360 t www.TFDVSFXPSLDPNQ.com Page 2 / 4 Request for Proposal Workers’ Compensation Questionnaire Y N RISK EXPOSURES Does applicant own, operate, or lease aircraft / watercraft? Any work performed under, on, or above water (i.e. vessels / boats, barges, docks, piers, bridges, divers, etc.)? Any work which may be subject to Jones Act, USL&H, or FELA? Any past, present, or discontinued operations which have involved exposure to chemicals, paint, or hazardous materials? Any work performed underground, or higher than 15 feet above ground level? If yes, please describe work. Any operations include excavation, tunneling, road boring, earth moving, or other underground work? Any operations exposure to radioactive / nuclear materials? Are athletic teams sponsored? Is applicant involved in any business other than what is specified in the description of operations? Y N SUB-CONTRACTOR / 1099 EXPOSURES Are any subcontractors used? If yes, list % of work subcontracted and description of work. If yes, are any subcontractors paid on a 1099 basis as an individual / self-employed, sole proprietor? How many? If yes, does applicant keep current copies of subcontractor’s Workers Compensation Certificates of Insurance? Do employees perform work for other businesses or subsidiaries? If yes, please explain. Y N TRAVEL / TRANSPORTATION EXPOSURES Do any employees predominantly work from home? If yes, please specify the # of employees. Do employees travel out of state? If yes, list states and % of out of state travel. Any employee group transportation or ride-share programs? Do any employees operate a company-owned vehicle or use their own personal vehicles for company business? Does the radius of operations of vehicles exceed 200 miles? Are MVR’s checked on all employees who drive for company business purposes? 4FDVSF8PSL$PNQ %PZMF$BSMUPO4VJUF t Tampa, FL 3360 t www.TFDVSFXPSLDPNQ.com Page 3 / 4 Request for Proposal Workers’ Compensation Questionnaire (cont.) BENEFITS / DISABILITY / HR RELATED Any seasonal employees? If yes, please specify below season and % of seasonal employees during the season. Any volunteer or donated labor? If yes, is a volunteer labor indemnification agreement used? (attach sample) Any employees under 16 or over 60 years of age? Any employees with physical handicaps? Does employee turnover exceed 30% annually? Are any employees enrolled in a group health care plan? If yes, what percentage? Is a “managed care” provider utilized? Are physicals required after offers of employment are made? Is a drug-testing program in effect? If yes, attach copy. Is an early return / light duty program in place? Does applicant “full pay” during periods of disability or reduced work? SAFETY / OSHA RELATED Is a written safety program in place? Does applicant provide new employee safety training / orientation? Does applicant hold regular safety meetings? If yes, describe how ofen. Does applicant conduct regular safety inspections? If yes, describe how often. Has applicant been inspected by OSHA in the past three years? Any fatalities in the past five years? If yes, attach claim details. PRIOR COVERAGE / CREDIT RELATED Any prior coverage declined, cancelled, or non-renewed in the past three years? Any tax leins or bankruptcy within the last five years? Any undisputed or unpaid workers compensation premium due from you or your commonly-owned businesses? Any workers compensation insurance coverage currently with Guarantee (GIC) or Lumbermans (LUA)? Electronic Signature: Date: 4FDVSF8PSL$PNQ %PZMF$BSMUPO4VJUF t Tampa, FL 3360 t www.TFDVSFXPSLDPNQ.com Page 4 / 4