EUROPEAN-AMERICAN INC.

Workers Compensation Insurance Questionnaire
Please complete and return to EurAm
Company Name Street
Type of Applicant City
Telephone: County
Telefax: State / Zip
Website e-mail
Years in business: Federal Employer ID Number
Locations: (Street, City, County, State and Zip Code)
1)
2)
3)
 
 
Policy Information
Part 1 Workers Compensation (States)
Part 2 Employer's Liability
Each Accident $    
Disease-Policy Limit $
Disease-Each Employee $
Part 3 Other States Insurance
Other Coverages Foreign Voluntary Compensation Disability Insurance
 
Theft Extension (Fine Arts, Silver, Jewelry, Furs, Coins, Stamps, Guns, etc.) please click here to fill out
separate sheet.
     
Rating Information    
Number of Full-Time Employees Number of Part-Time Employees Estimated Annual Remuneration
1) $
2) $
3) $
Duties and Classifications (i.e. Sales, Executive, Clerical)
1)
2)
3)
 
 
Individuals included / excluded
Name Date of Birth (mo/day/year) Title/Relationship Ownership %
1)
2)
3)
4)
5)
 
Duties Included/Excluded Annual Remuneration
1) $
2) $
3) $
4) $
5) $
 
Prior Carrier Information / Loss History
Year Insurance Company Policy Number Annual Premium
1)
2)
3)
4)
5)
 
MOD No. of Claims Amount Paid Reserve
1)
2)
3)
4)
5)
 
 
Nature of Business / Description of Operations
Description of Operations and/or Products:
Manufacturing - Raw Materials, Processes, Products, Equipment.
Contractor-Type of Work, Subcontracts, Mercantile-Merchandise, Customers, Deliveries.
Service-Type: Location, Farm-Acreage, Animals, Machinery, Subcontracts.
If possible submit a brochure or your products or service via mail.
 
 
General Information (Explain all "YES" answers)
1) Does applicant own, operate or lease aircraft/watercraft? YES NO
2) Do/have past, present or discontinued operations involve(d) storing, treating, or discharging, applying, disposing, or transporting of hazardous material, e.g. landfills, wastes, fuel tanks, etc.)? YES NO
3) Any work perfomed underground or above 15 feet? YES NO
4) Any work performed on barges, vessels, docks, bridges over water? YES NO
5) Is applicant engaged in any other type of business? YES NO
6. Are subcontractors used? (If yes, give % of work subcontracted.) YES NO
7. Any work sublet without certificates of insurance? YES NO
8. Is a formal safety program in operation? YES NO
9. Any group transportation provided? YES NO
10. Any employees under 16 or over 60 years of age? YES NO
11. Any seasonal employees? YES NO
12. Is there any volunteer or donated labor? YES NO
13. Any employees with physical handicaps? YES NO
14. Do employees travel out of state? YES NO
15. Are athletic teams sponsored? YES NO
16. Are physicals required after offers of employment are made? YES NO
17. Any other insurance with this insurer? YES NO
18. Any prior coverage declined / canceled / non-renewed last 3 years (not applicable in Missouri)? YES NO
19. Are employee health plans provided? YES NO
20. Is there a labor interchange with any business / subsidiary? YES NO
21. Are employees leased to or from other employers? YES NO
22. Do any employees predominantly work at home? YES NO
 
Please explain all "YES" asnwers:
     
 
APPLICABLE IN TENNESSEE; IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKER COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFIT.
 
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE 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 AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES.
 
 
Remarks:


Note: Completion of this questionnaire does not constitute a binder or obligate the applicant to purchase this insurance.

Desired Effective Date    
Name: Title: Date: