workers compensation premium indication form architects ... - Willis

Firm Name:WORKERS COMPENSATION PREMIUM INDICATION FORMARCHITECTS/ENGINEERSEffectiveDate:Address:FEIN No.: Individual Partnership Corporation Other:Current Carrier (if any) Name, Policy No and Policy TermClassification (see descriptions below) Annual Payroll No. of Employees8601 - Architects/Engineers – Consulting8810 – Drafting/Graphic Designer8810 - Clerical/Administrative8742 - SalesSole Proprietors and Partners are automatically EXCLUDED UNLESS SPECIFICALLY INCLUDED.Corporate Officers are INCLUDED UNLESS SPECIFICALLY EXCLUDED.INDIVIDUALS TO BE INCLUDED OR EXCLUDED – Above payroll should reflect suchName Title/Annual Payroll (only if Included) Include/ExcludeComments/AdditionalInformation:8601 - Architects/Engineers – Consulting/Land Surveying: This classification is applicable to insuredsengaged in the architectural or engineering profession as a separate and distinct business. Operationsconducted by these firms include consultation with clients; research on behalf of clients; site inspections;and the compilation of information to enable these firms to make recommendations to their clients. Theserecommendations may be in the form of written or electronic media and include plans, maps, charts andspecifications.8810 - Drafting/Graphic Designer. This classification is applicable to those whose duties are limited tocreating original pictures or designs or preparing copy for reproduction, or preparing drawings and who donot travel away from the office.8810 - Clerical/Administrative. This classification is applicable to office personnel whose duties are limitedto regular clerical or administrative duties and who do not travel away from the office.8742 - Sales. This classification is applicable to employees who regularly leave the office to solicit businessor to call on clients. This category does not apply if the employee visits job sites.Edition Date September 19, 2005 Page 1 of 2

WORKERS COMPENSATION PREMIUM INDICATION FORMARCHITECTS/ENGINEERS CONT.General Information (Please explain all “Yes” responses) Yes No1. Does applicant own, operate or lease aircraft/watercraft?2. Do/have past, present or discontinued operations involve(d) storing, treating,discharging, or transporting of hazardous material? (e.g. landfills, waste fuel tanks,etc)3. Any work performed underground or above 15 feet?4. Any work performed on barges, vessels, docks, bridge over water?5. Is applicant engaged in any other type of business?6. Are sub-contractors used? (If yes, give % of work subcontracted)7. Any work sublet without certificates of insurance?8. Is a formal safety program in operation?9. Any group transportation provided?10. Any employees under 16 or over 60 years of age? (Do Not Respond) ------ ------11. Any seasonal employees?12. Is there any volunteer or donated labor?13. Any Employees with physical handicaps? (Do Not Respond) ------ ------14. Do employees travel out of state?15. Are athletic teams sponsored?16. Are physical required after offer of employment are made?17. Any other Insurance with this Insurer?18. Any prior coverage declined/canceled/non-renewed (last 3 years)?Not applicable in MO.19. Are employee health plans provided?20. Is there a labor intercharge with any other business/subsidiary?21. Do you lease employees to or from other employers?22. Do any employees predominantly work at home?Claims? Yes/No (circle one)If yes, please describe any claim in detail including amounts paid.Please attach claim loss run from current carrier (if any)Please attach NCCI Experience Modification Worksheet (if any)Edition Date September 19, 2005 Page 2 of 2