Worker’s Compensation – Baker, Romero & Associates Insurance Brokers

#Employees Full-Time

Please enter a number greater than or equal to 1.

#Employees Part-Time

#Employees Volunteers

If not, who is eligible?

Name of Healthcare Provider:

# of Authorized Drivers:

What purpose do employees drive?

Frequency of MVR checks:

How many vehicles have a capacity of 15 passengers or more?

# of employees allowed to ride?

For vehicles with passenger capacity >15 passengers or over 10,000 GVW, please complete the following:

Gross Vehicle Weight

NONPROFITS:

Please provide the names of your nonprofit’s board members below:

Vice President/ Vice Chair:

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:

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.

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# of Full-Time Employees

# of Part-Time Employees

Estimated Annual Payroll

# 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:

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.

Number of Paid Interns

Estimated Annual “Payroll”:

Description of work:

WAIVER OF SUBROGATION ENDORSEMENT

Please advise if you have any contracts or agreements that require a Waiver of Subrogation Endorsement

Worker's Compensation

Contact Information

PRIOR PAYROLL, PREMIUM, & INSURANCE CAREER

GENERAL INFORMATION

Benefits

HIRING PRACTICES

VEHICLE USE

For vehicles with passenger capacity >15 passengers or over 10,000 GVW, please complete the following:

#2

#3

NONPROFITS:

For-Profit Ownership: Please provide the list of owners & their titles with the percentage of ownership:

LOCATION & PAYROLL PER LOCATION

INDEPENDENT CONTRACTORS & INTERNS

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:

UNPAID INTERNS

Paid interns are required to be covered under your workers’ compensation policy.

WAIVER OF SUBROGATION ENDORSEMENT

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