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Workers Compensation Quotation Request Form

* required field
Agent Name:*
Email Address:*
Phone Number:*

If you have PREFILLED FORMS please attach PDF copies of the Acord, Supplemental application and Loss Runs by UPLOADING FORMS HERE.

To manually enter the necessary information please fill the form below.

Named Insured:*
Proposed Effective Date:*
Years in Business:*
Contact Name:*
Contact Phone #:*
Owner(s) Name:*
Class Code:*
Each Accident ::: Disease/Policy ::: Disease/Employee:*
Description Class Code Full Time Employees # Part Time Employees # Payroll
Experience Mod:*
Description of Operations:*
Current General Liability Policy Carrier:*
Current General Liability Policy Number:*
Current General Liability Policy Effective Dates:    to   
Past 3 years of Work Comp and General Liability Premiums
Year W/C Premium G/L Premium
Check all that apply:   Written Application    Reference Checks    Validate Work History   
 Formal Interview    Criminal Background Check    Audio Testing   
 Pre/Post Employment Physical    Orthopedic Back Test    Substance Abuse Testing   
 Child Abuse Clearance   
Do you perform drug and alcohol screening as follows:   
Pre-placement?   Yes    No
Post accident?   Yes    No
Random testing?   Yes    No
How are potential new employees hired (check all that apply)?   Referrals    Word of Mouth    Public Advertisements   
 Recruiters    Union Hall   
 Other, Please describe:    
Do you offer a majority of your employees who work over 30 hours a week Health Insurance?   Yes    No
If yes, do you pay at least 50% of the Health Insurance Premium?   Yes    No
Do you have a written Safety Program?   Yes    No
(Subject to review for compliance with OSHA/industry regarding weather protection, fire prevention/smoking control, provisions for and enforced use of other protective equipment, ladder/fall protection, manual material handling practices/training, vehicle rigging, warranty compliance, etc.).:   
Are your foreman trained to recognize signs of: heat stroke, frostbite, dehydration, and vapor intoxication?   Yes    No
Designated full time safety director?   Yes    No
Who is responsible for job site activities? 
Who is responsible for investigating accidents and near misses? 
How do you ensure that corrective actions are completed? 
Are foreman certified in First Aid and CPR?   Yes    No
Are your foreman part of a working crew?   Never    Sometimes    Always   
Do you have a designated safety committee?   Yes    No
If Yes, how frequently does the committee meet?   Daily    Weekly    Monthly    Annually   
Does the safety committee present their findings to a management team?   Yes    No
What is reviewed by the safety committee during their meetings? 
Safety meetings held for all employees?   Yes    No
Safety training program in place for employees?   Yes    No
Safety incentive program?   Yes    No
What is the incentive? 
Slip & Fall prevention program?   Yes    No
Proper lifting program?   Yes    No
Are your employees required to wear Personal Protective Equipment? (Check all that apply.):   Hard Hats    Safety Glasses    Gloves   
 Hearing Protection    Steel Toed Boots   
 Other, Please describe:    
Equipment safeguards utilized?   Yes    No
Equipment inspection/maintenance program?   Yes    No
If yes, describe: 
Hazardous materials communication program?   Yes    No
Accident investigation program?   Yes    No
Are supervisors held accountable for injuries?   Yes    No
Please identify the individual in charge of risk management or your safety program and his contact telephone number: 
Do you have a written return to work program including modified duty or early return-to-work?   Yes    No
With full pay?   Yes    No
   Written    Informal   
Are you willing to implement safety recommendations made by the carrier and/or loss control?   Yes    No
Please indicate if you offer:   Employee Assistance Program    Paid Vacations    Paid Sick Leave   
Do you have a minimum of two employees?   Yes    No
Is a regular inspection for housekeeping hazards and condition of equipment performed?   Yes    No
If so, how often and by whom? 
Do employees perform maintenance, custodial work, and/or landscaping or yardwork at your facilities?   Yes    No
Is there a driver safety program?   Yes    No
Are MVR's run?   Yes    No
How often? 
Describe MVR acceptability criteria and procedures for dealing with unacceptable drivers and violations: 
What is the driving distance?   <50 miles    51-100 miles    >100 miles   
Frequency of driving?   Daily    Weekly   
 Other, Please describe:    
Number of company vehicles? 
Number of employees authorized to operate company vehicles? 
What is the purpose of the driving exposure? 
Do more than 3 employees travel together in any one vehicle?   Yes    No
Do employees take company vehicles home?   Yes    No
Vehicles inspection/maintenance program?   Yes    No
Do you perform Asbestos removal, hazardous material abatement, or pollution cleanup?   Yes    No
Please complete the table below (numbers should total 100%):   
Type of work performed % New Construction % Renovation or Repair
Commercial % %
Industrial % %
Residential % %
Do you participate in projects where another contractor or the project owner provides coverage for all contractors involved in the project (also known as OCIP/wrap up projects)?   Yes    No
If residential work is performed, please indicate the percentage of the following related to your residential operations:   
New Tract homes:  %
New Custom Homes:  %
Condos/Townhomes:  %
Apartments:  %
Other:  %
Do you use subcontractors?   Yes    No
If you answered yes please complete below:   
Do all of your subcontractors carry their own Workers Compensation Insurance?   Yes    No
Do you always collect a certificate of insurance indicating Workers Compensation Insurance coverage or proof of exemption from Worker's Compensation Insurance from your subcontractors?   Yes    No
Do you issue IRS form 1099 or its equivalent to your subcontractors?   Yes    No
Do you pay subcontractors in cash or barter exchange?   Yes    No
Do you maintain complete and accurate records of funds you pay to subcontractors?   Yes    No
How many years of experience in the roofing profession as your primary activity? 
Do you perform hot-tar applied roofing systems?   Yes    No
If yes, what percentage of your work involves hot tar applied applications?  %
Do you perform torch applied roofing operations?   Yes    No
If yes, what percentage of your work involves torch applied applications?  %
Do you perform polyurethane spray foam roofing applications?   Yes    No
If yes, what percentage of your work involves polyurethane foam applications?  %
Do you perform metal roofing?   Yes    No
If yes, what percentage of your work involves metal roofing?  %
Do you provide a fire watch on any project involving hot-tar or torch applications during breaks, absences, and after completion?   Yes    No
Do you have available fire extinguishers or other fire suppression equipment during hot-tar or torch applications including fire watch?   Yes    No
What is the maximum number of stories high you will perform work? 
What is the maximum roof pitch you work on? 
Do you have designated employees for Hot Work?   Yes    No
Do you perform pre-work rooftop inspections to confirm strength and weakness areas?   Yes    No
If "Yes", please describe: 
Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY substantial)civil penalties (not applicable in CO, FL, HI, MA, NE, OH, OK, OR VT; in DC, LA, ME, TN, and WA, insurance benefits may also be denied) In 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 third degree.:   



Shield Commercial Insurance Services, Inc.
43-725 Monterey Ave, Ste A. Palm Desert, CA 92260
Tel: 760-345-9029 Fax: 800-345-4851
CA License Number: 0E67754