Workers Compensation & Employers Liability Insurance Quote Information for the HF Thompson Insurance Agency. Applicant Information

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1 The Thompson Agency wants to help you evaluate and improve upon your current employee safety practices, reducing the incidence of on-the job injuries while serving your patients or clients as Home Healthcare workers. As a customer of the Thompson Agency, we can help you secure cost-saving templates for safety procedures, loss control resources and accident prevention information that is specifically related to the Home Healthcare Industry. Applicant Name: DBA: N/A FEIN/SSN: State: Bureau ID: Mailing Address: City/State/Postal Code: Applicant Information Insurance Contact Name: Insurance Contact Phone: Insurance Address: Loss Control Contact Name: Loss Control Contact Phone: Loss Control Address: Accounting Contact Name: Accounting Contact Phone: Accounting Address: Business Description: Home Health Care NAICS # Policy Information Desired Effective Date: Anniversary Date*: (* inception date of your last policy) Desired Expiration Date: Policy Number: Legal Entity: (Corporation, LLC, etc.): Number Years in Business or Mo/Yr established:

2 Owner/Officer Name: Title: State whether to be Included/Excluded: (Estimated Annual Payroll) Remuneration: $ Note: if more than one individual, include the above data for each Owner/Officer Locations of the Named Insured: Address: City: State: Postal Code: Location #1 Location #2 Employers' Liability Limits of Insurance Desired Each Accident: (VA Standard) $ 100,000 or higher limit of: $ Disease-Policy Limit: (VA Standard) $ 500,000 or higher limit of: $ Disease-Each Employee: (VA Standard)$ 100,000 or higher limit of: $ Rating Information State Location Classification Code Class Description Estimated/Projected Annual (Payroll) Remuneration Prior Loss History Please attach 5 year loss data or Provide information below for 0-5 yr history (if in business less than 5 years) expired policy data so that we may prepare a Loss or Claim Data Request letter for your signature and subsequent request to the Carrier:

3 Policy Year Carrier Name Policy Number Insured's Statement Prequalification Please Circle Yes or No- If Yes, please describe under Remarks: 1. Own, operate or lease aircraft/watercraft? Yes or No 2. Past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous materials? (e.g. landfills, wastes, fuel tanks, etc.) 3. Work performed on barges, vessels, docks or bridges over water? Yes or No 4. Work performed underground or above 15 feet? Yes or No 5. Demolition, blasting or explosive manufactures, haulers or distributors? Yes or No 6. Professional sport teams and/or professional athletes? Yes or No 7. Asbestos abatement, manufacturing or distribution? Yes or No 8. PEO, ASO or temporary employment services or employees leased to or from other employees? Yes or No 9. Public and/or Governmental entities that employ fire, police and/or correctional officers? Yes or No 10. Surface, underground mining and/or hauling of coal? Yes or No 11. Owner/proprietor is the only employee seeking workers compensation coverage? (11) Yes or No REMARKS TO YES Answers to Questions 1-11, above: Insured's Statement 1. Is applicant engaged in any other type of business? Yes or No 2. Is any work subcontracted without certificates of Insurance? Yes or No 3. Is a written safety program in operation? Yes or No 4. Is there any group transportation provided? Yes or No 5. Are any employees under 16, or over 65 years of age? Yes or No 6. Are there any seasonal employees? Yes or No 7. Is there any volunteer or donated labor? Yes or No

4 8. Are there any employees with physical handicaps? Yes or No 9. Do employees travel out of state? Yes or No 10. Has any prior coverage been declined/ cancelled/ non-renewed in last 3 years? (Not applicable in Missouri) Yes or No 11. Are employee health plans provided? Yes or No 12. Is there a labor interchange with in any other business/ subsidiary? Yes or No 13. Do any employees predominantly work at home? Yes or No 14. Have there been any tax liens or bankruptcies within the last 5 years? Yes or No 15. Is this business entity residential-based? Yes or No 16. Does the applicant, or the manager of this business have less than three years of management experience in the industry? Yes or No 17. Does the applicant have or will the applicant implement a return to work program with modified or transitional jobs to accommodate the injured employees? Yes or No If Yes, please attach a copy of Company Policy /Procedure or be prepared to provide at binding. Please provide the following necessary underwriting documents: Current Dec Page or Policy showing Limits & Retro Dates Current NCCI Mod Report if available Current Audited Financial Statement (if budget exceeds $5M) Current Home Health Care Licenses Current Federal & State Complaint Investigations in the last 12 mos. If recent new entity, name change, or change in ownership: ERM-14 completed by Insured prior to binding (Let us know if you need this form) If any individuals are to be EXCLUDED, as per guidelines of Acord 171A/VA WC VA 16 A (copy attached) please submit the completed 171A/16Aform prior to binding.

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