Excess Compensation Application

Transcription

1 Excess Compensation Application Applicant s Representative Address New Application Renewal of policy Effective Date Quote needed by 1. Name of applicant and subsidiaries (List only qualified self-insureds.) 2. Mailing address 3. Description of operations, processes and products of applicant and subsidiaries (Attach copy of current and comprehensive loss prevention inspection reports, product brochure, annual report or 10-K report, and copy of self-insured application filed with the state.) 4. In which states or jurisdictions will applicant operate as a qualified self-insured? 5. Date applicant qualified as a self-insured 6. Service company / TPA information (If no claims service company, attach or request a Claims Administration Questionnaire.) A. Claims administration services 1. Name of service company 2. Address of service company 3. Service company contact and telephone number 4. Provide details of types of service that will be provided by service company 5. Is service company responsible for providing specific excess claim reporting and follow-up detail to excess carrier? yes no If no, who is responsible? 6. Does service contract require that claims be handled to conclusion? yes no. If no provide details. 7. How many years has service company had service contract with applicant? 8. Is service contract concurrent with policy period? yes no If no, what are the effective and expiration dates of service 9. Loss runs concurrent with policy period must be provided on a quarterly basis. Provide name, address and telephone number of individual responsible for providing loss runs NOTE: Any change in service company or in the kind or amount of service must be immediately communicated to and approved by excess carrier. B. Loss prevention service 1. Name of service company 2. Address of service company 3. Provide details of types and frequency of services that will be provided by service company 4. (a) Does applicant have a formal safety program? yes no If yes, attach copy. (b) Does the program include proper lifting techniques? yes no (c) Are lifting devices used? yes no 1

2 5. Does applicant agree to forward copies of loss prevention inspection reports to excess carrier as inspections are performed? yes no 6. Has the applicant developed a plan or strategy to deal with a potential outbreak of avian flu? yes no 7. Current program A. Name of present workers compensation carrier (primary or excess) B. If fully insured, describe type of plan C. Complete the following if presently self-insured Specific Excess Employer s Liability Self-Insured Retention Aggregate Excess Loss Fund % Minimum Term Loss Fund 8. Coverage desired (Indicate all alternatives to be considered.) Specific Excess Employer s Liability Self-Insured Retention Aggregate Excess Loss Fund % Minimum Term Loss Fund 9. Specify additional coverages or endorsements desired 10. Provide the following information regarding each state or jurisdiction to be covered (Attach supplemental page if additional Space is required.) W. C. Code No. Classification No. of Employees Estimated Annual Payroll or Manhours Current Manual Rates Manual Premium 11. Vehicle Operation: A. Does the applicant own, lease, operate or provide a shuttle bus or van to transport employees? yes no If yes, a schedule of vans or buses must be provided with a complete description of the shuttle operation, including average number of employees per trip, number of trips per day and distance traveled. B. Does the applicant own, lease, operate or provide staff for any ambulance service? yes no If yes, please provide a schedule of any owned, leased or operated ambulances and a complete description of the operation, including radius of operation, frequency of dispatch, etc. 12. Aircraft Operation: A. Does the applicant own, lease, charter or operate a fixed wing aircraft or helicopter? yes no If yes, an aircraft supplemental application must be completed. B. Does the applicant provide medical staff for any fixed wing or helicopter operations? yes no If yes, a complete description of the operation must be provided, including the number of employees in any one aircraft or helicopter, average number of trips, average number of employees per trip, and the estimated monthly flight hours for each aircraft. 13. Watercraft Operation: A. Does the applicant own, lease, charter or regularly use any watercraft? yes no If yes, a watercraft supplemental application must be completed. 2

3 14. Healthcare Operation: A. Is applicant in compliance with all applicable OSHA, CDC or other regulatory standards for handling of ethylene oxide, blood borne pathogens, infectious diseases and sterilization of instruments? yes no. Please explain any no answer and detail any regulatory citation in the past five years B. Does any facility owned or operated by the applicant provide clinical testing for HIV, specialize in the treatment of AIDS or HIV, or conducts AIDS or HIV research? yes no. If yes, please explain and provide the approximate number of AIDS patients treated annually. C. Describe any Home Health Care provided by the applicant, including number of employees in Home Health, the classification of those employees (RN, LPN, Nurses Aids), the number of visits per month and the average distance traveled. D. Will non-compensated volunteers be covered by this insurance? If yes, please provide the following: Description of duties No. of volunteers annual hours worked 15. Special Exposures: Check the appropriate box applicable to actual or anticipated exposures and provide answers to any yes answers: A. Are there any leased employees? yes no If yes, what are their dutues and who is responsible for their workers compensation coverage? B. Operations or employees subject to Longshoreman s Act or Maritime (Jones) Act? yes no C. Foreign Operations or employees who travel to foreign countries? yes no D. Operations which have resulted in carpal tunnel, repetitive motion or cumulative trauma claims? yes no E. Store or transport gasoline, flammables or other gasses? yes no F. Any OSHA violations in the past five years? yes no G. Any substantial or unusual changes in operations planned in the next 12 months? yes no H. Any substantial changes that have taken place in the past five years? yes no I. Workers compensation coverage cancelled or non-renewed in the last five years? yes no J. Any occupational disease exposures? yes no Explanation of any Yes answers or other remarks: 16. Loss experience (Attach supplemental page if additional space is required.) A. Provide five-year loss history for each state to be included in proposed coverage. (Loss experience must be summarized even if submitting loss runs. Break out losses by year. Valuation date must be within last six months.) Policy Period MO/DAY/YEAR Audited Payrolls or Manhours Exp. Mod Indemnity Paid Indemnity Medical Paid Medical Claims Expense Incurred Valuation Date B. Provide the following information concerning all death and permanent total disability claims and all claims with total incurred costs in excess of $50,000 in the last five years. Date of Loss No. of Emp. Involved Claimants Name (s) Description of Loss and Nature of Injury or Disease 3 Paid Incurred Open or Closed

4 C. Is information taken from loss runs? yes no If no, provide source. D. Are loss runs submitted with application? yes no If no, are loss runs available upon demand? yes no This is NOT a binder of coverage. The application must be signed by the applicant or the applicant s representative. The applicant represents that all statements made in this application are complete and true and that all material facts have been fully disclosed. FRAUD WARNING STATEMENTS Colorado It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Florida Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. New Jersey Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New York Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Washington It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. All Other s Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or 4

5 conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Applicant s Representative Applicant Signature Date Title Premier Insurance Management Services, Inc., a wholly owned subsidiary of Premier, Inc. does business as Premier IMS Insurance Services in California and Premier I.M.S. Insurance Agency in Oklahoma and New York. PEWCA 5/08 5