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Our Address
750 Terrado Plaza, Suite 238 Covina, CA 91723
lillian@bakerromero.com
(626) 332-2258
Everyday 9:00am - 6:00pm
Worker's Compensation
Contact Information
Organization Name:
(Required)
FEIN No:
Effective Date:
MM slash DD slash YYYY
Contact Name & Title:
Phone Number:
Fax Number:
Contact Email:
Web Address:
Indicate if for Profit or Non Profit
For Profit
Non Profit
PRIOR PAYROLL, PREMIUM, & INSURANCE CAREER
Current Year
MM slash DD slash YYYY
Premium, & Insurance Carrier
Total Annual Payroll
Premium $
Prior Year
MM slash DD slash YYYY
Premium, & Insurance Carrier
Total Annual Payroll
Premium $
Prior Year
MM slash DD slash YYYY
Premium, & Insurance Carrier
Total Annual Payroll
Premium $
Prior Year
MM slash DD slash YYYY
Premium, & Insurance Carrier
Total Annual Payroll
Premium $
Prior Year
MM slash DD slash YYYY
Premium, & Insurance Carrier
Total Annual Payroll
Premium $
GENERAL INFORMATION
Years in Business:
No. of Locations:
Hours of Operation:
Description of Operations:
Present number of employees:
Full-Time
Part-Time
Seasonal
Volunteer
#Employees Full-Time
Please enter a number greater than or equal to
1
.
#Employees Part-Time
#Employees Seasonal
#Employees Volunteers
Percent of employee turnover in last 12 months
Full-Time
Part-Time
%Full-Time
%Part-Time
Employee staffing expectation over the next 12 months:
Full-Time
Part-Time
Full-Time
Part-Time
Average hourly wage
Full-Time
Part Time
$ Full-Time
$ Part-Time
Benefits
Are ALL employees eligible?
Yes
No
If not, who is eligible?
Paid Sick Leave
Yes
No
% Paid by Employer
% of participation
Group Health
Yes
No
% of participation
% Paid by Employer
Vacation
Yes
No
% Paid by Employer
% of participation
Retirement/Pension Plan
Yes
No
% Paid by Employer
% of participation
Name of Healthcare Provider:
Full time nurse maintained on staff?
Yes
No
CPR Training Provided?
Yes
No
Would you participate in a MPN (Medical Provider Network) program to control claim costs?
Yes
No
Safety activities currently established & practiced regularly?
Yes
No
Written safety program compliant with state labor code?
Yes
No
Return to light duty plan?
Yes
No
Includes full wages?
Yes
No
Return to Full-time modified work plan?
Yes
No
Designated Full-Time Safety Director?
Yes
No
Safety meetings?
Yes
No
Frequency
Safety Training held for all employees?
Yes
No
Incentive Program for Employees:
Yes
No
Personal Protective Safety Equipment provided for all employees where necessary:
Yes
No
Supervisors held accountable for injuries/accidents:
Yes
No
Accident investigation protocols?
Yes
No
HIRING PRACTICES
Employment Application?
Yes
No
Drugs/Substance abuse?
Yes
No
Reference Checks?
Yes
No
Audiometric Testing?
Yes
No
Pre/Post Employment Physical?
Yes
No
Orthopedic back Test?
Yes
No
VEHICLE USE
Operations incl. vehicle exposure (company owned/personal)?
Yes
No
# of Authorized Drivers:
# of Vehicles:
What purpose do employees drive?
Driving frequency:
Daily
Weekly
Other
Specify
Driving Radius:
<50: 51-100
101-250
>250
Frequency of MVR checks:
Participation in an MVR Pull program:
Yes
No
Driver acceptability standards established:
Yes
No
Employees take vehicles home at night?
Yes
No
Vehicle inspection/maintenance program:
Yes
No
Frequency:
Vehicle inspection/maintenance program:
Yes
No
Any BIT inspections with unsatisfactory rating:
Yes
No
Employees maintain vehicles:
Yes
No
If Not, who:
How many vehicles have a capacity of 15 passengers or more?
# of employees allowed to ride?
Do company vehicles transport non-employee passengers?
Yes
No
Clients only?
Yes
No
Do you have a driver safety program?
Yes
No
For vehicles with passenger capacity >15 passengers or over 10,000 GVW, please complete the following:
Year
Make & Model
Garage Location
Driving Radius
Ann. Mileage Driven
Gross Vehicle Weight
Retail Deliveries
Yes
No
#2
Year
Make & Model
Garage Location
Driving Radius
Ann. Mileage Driven
Gross Vehicle Weight
Retail Deliveries
Yes
No
#3
Year
Make & Model
Garage Location
Driving Radius
Ann. Mileage Driven
Gross Vehicle Weight
Retail Deliveries
Yes
No
NONPROFITS:
Please provide the names of your nonprofit’s board members below:
President/Chair
Vice President/ Vice Chair:
Vice President/ Vice Chair:
Secretary:
Treasurer:
If board members are compensated please provide the estimated annual payroll, description of their duties, and their work location (if applicable) in the comment section BELOW
For-Profit Ownership: Please provide the list of owners & their titles with the percentage of ownership:
#1. Name of Owner
Title
Percentage of ownership
#2. Name of Owner
Title
Percentage of ownership
#3. Name of Owner
Title
Percentage of ownership
#4. Name of Owner
Title
Percentage of ownership
#5. Name of Owner
Title
Percentage of ownership
LOCATION & PAYROLL PER LOCATION
INCLUDE: Wages, salaries, commissions, cash payments to subcontractors, bonuses, vacation, holiday, sick pay, and straight pay for overtime hours. DO NOT Include: Overtime pay in excess of straight pay for the employee, wages of subcontractors that provide you with a valid certificate of workers’ compensation coverage.
Location 1
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
#2
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
#3
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
Location 2
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
#2
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
#3
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
Location 3
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
#2
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
#3
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
Location 4
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
#2
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
#3
Class Code
Classification
# of Full-Time Employees
# of Part-Time Employees
Estimated Annual Payroll
INDEPENDENT CONTRACTORS & INTERNS
INDEPENDENT CONTRACTORS
If your organization contracts with independent contractors and they do not carry their own insurance, We recommend that you add them to your workers’ compensation policy. If you would like to add coverage for your independent contractors to your policy please provide the following information:
# of Independent Contractors:
Estimated “payroll” (pay for service/project)
Description of work:
INTERNS
Paid Interns
Unpaid Interns
UNPAID INTERNS
We recommend that unpaid interns be covered under a volunteer-accident policy. Let us know if your organization does not currently carry volunteer-accident coverage and would like us to provide a quote.
Paid interns are required to be covered under your workers’ compensation policy.
Does your organization hire paid interns?
Yes
No
Number of Paid Interns
Location
Estimated Annual “Payroll”:
Description of work:
WAIVER OF SUBROGATION ENDORSEMENT
Do you have any contracts or agreements that require a Waiver of Subrogation Endorsement?
Yes
No
Name
Address
Street Address
Please advise if you have any contracts or agreements that require a Waiver of Subrogation Endorsement
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