Workers' Compensation Application

Application for Worker's Compensation
Requested Effective Date*

MonthDayYear
Business Name*
DBA
Business Mailing Address*
County*
Business Owner Name*
Business Phone Number*
Business Fax Number
State License Number
FEIN/SSN*
Website
Main Contact Person
Main Contact Phone Number
Email Address*
Please describe your business operations:*
Where does your business operate?*

I run my business out of my homeI lease a space from othersI work at a job siteI run my business from property I ownI own a property and lease to others
Years in Business*
Experience in Industry*
Type of Business

CorporationIndividualPartnershipJoint VentureLLCOther type of business
Annual Sales
Annual Payroll*
Number of Employees*
What % of annual sales are through subcontractors?
Who is your prior insurance carrier?
What are your operating hours?

Please send any additional information to submissions@whiteeagleca.com. *

	Yes	No	If 'Yes', please explain:
Any prior coverage declined/cancelled/non-renewed in the last 3 years? (Missouri applicants, do not answer this question.)
Have any claims been made in the past 3 years?
Do you deliver any of your products to customers?
Do any of your employees carry firearms on the premises?
Is security provided by an independent security guard service?
If yes, do contracted security guards carry firearms on the premises?
Are any products sold online?
Are background checks done on all employees?
Does applicant own, operate, or lease aircraft/watercraft?
Do/have past, present, or discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting of hazardous material? (e.g. landfill, wastes, fuel tanks, etc.)
Any work performed underground or above 15 feet?
Any work performed on barges, vessels, docks, bridge over water?
Is applicant engaged in any other type of business?
Any work sublet without certificates of insurance? (If 'Yes', payroll for this work must be emailed to submissions@whiteeagleca.com)
Is a written safety program in operation?
Any group transportation provided?
Any employees under 16 or over 60 years of age?
Any seasonal employees?
Is there any volunteer or donated labor? (If 'Yes', please specify.)
Any employees with physical handicaps?
Do employees travel out of state? (If 'Yes', indicate state(s) of travel and frequency.)
Are athletic teams sponsored?
Are physicals required after offers of employment are made?
Any other insurance with this insurer?
Are employee health plans provided?
Do any employees perform work for other businesses or subsidiaries?
Do you lease employees to or from other employers?
Do any employees predominantly work at home? (If' Yes', list # of employees.)
Any tax liens or bankruptcy within the last 5 years? (If 'Yes', please specify).
Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? (If 'Yes', please explain and include entity names and policy numbers.)

Do you need to add any Additional Insured?

YesNo
Specify Additional Insured
Location Information
Location#1 Address*
Construction*

FrameJoisted MasonryNon-combustibleMasonry NCFire Resistive
Add additional location?

YesNo
Location #2 Address
Construction

FrameJoisted MasonryNon-combustibleMasonry NCFire Resistive
Add additional location?

YesNo
Location #3 Address
Construction

FrameJoisted MasonryNon-combustibleMasonry NCFire Resistive
Add additional location?

YesNo
For additional locations, please email the information to submissions@whiteeagleca.com.
Employee Information
EMPLOYEE TYPE - Please enter the types of jobs that your employees have. For example: Administrative, Field Laborer, Sales, Management

NUMBER OF EMPLOYEES - Please enter the # of employees that have this type of job.

CLASS CODE - Please enter the class codes associated with each employee type. You can find the class codes you're insured for on your current workers compensation policy declaration page. If you're not sure what the class codes are, you can answer N/A to this section and provide a detailed description of employee duties to help us find them for you.

ANNUAL PAYROLL - Please enter the TOTAL annual compensation for all the employees that have this type of job.
Owners / Officers / Partners Information
Executive officers and directors of corporations must be included in Workers’ Compensation coverage, unless the corporation is fully owned by the directors and officers. If the directors and officers fully own the corporation, they can choose to be excluded from coverage. Sole proprietors without employees can opt out of coverage.
Do you need a Waiver of Subrogation?

YesNo
APPLICANT’S WARRANTY STATEMENT: I have read this application and I declare that to the best of my knowledge and belief, all of the foregoing statements are true and accurate, and that these statements are offered as an inducement to issue the policy for which I am applying. I agree that all representations made in this application are material and may be relied upon by the Underwriters in issuing the policy. If it is found that I knowingly provided false information to White Eagle Insurance Solutions in this application for insurance, I understand that any policy put in place using that information will be considered void and
no coverage will be provided.

FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Please verify that you are human*
Print Name
Notes / Comments
Agency
Agent
Should be Empty:

Application for Worker's Compensation