Mcdonalds Workers Compensation Application printable pdf download

WORKERS’ COMPENSATION APPLICATION

KAH Insurance Brokerage, Inc.

510 Broadhollow Road  Suite 210  Melville  NY 11747

Phone (631) 271-1721  Fax (631) 271-1723  Email:





If you already have an application completed for another carrier you can send that application instead.

Owner Operator Name:

Effective Date:

Named Insured/Corporate Name:

Primary FEIN:

Mailing Address:

City:

State:

Zip:

Region:

Telephone:

Fax:

Email:

Contact:

CLAIMS Contact & Email:

 Individual

 Corporation

 Partnership

 LLC

 Other

Year Business Established:

Total Stores:_________ # Freestanding:_________ # Other:_________ # Offices:_________ # Warehouses:________

Current Experience Mod:

Current Carrier:

Current Premium:

Names of all

Workers

Annual Remuneration

% of

Primary Duty

Owners / Officers

Compensation

*Do not include in payroll

Title

Ownership

(Please check one)

estimates on following page.

(If more, write on separate sheet)

(Please check one)

 Include

 Restaurant

 Exclude

 Administrative

 Include

 Restaurant

 Exclude

 Administrative

 Include

 Restaurant

 Exclude

 Administrative

GENERAL QUESTIONS:

Please comment on any yes responses on a separate sheet.

○ YES

○ NO

Do you deliver?

○ YES

○ NO

Any business owned vehicles?

Do you have any past, present or discontinued operations involved in storing,

○ YES

○ NO

treating, discharging, applying disposing or transporting of hazardous material?

○ YES

○ NO

Any employees under 16 years of age?

○ YES

○ NO

Any seasonal employees?

○ YES

○ NO

Do employees travel out of state?

○ YES

○ NO

Does the applicant own, operate of lease aircraft/watercraft?

○ YES

○ NO

Is the application involved in any other business?

○ YES

○ NO

Any subcontractors used?

○ YES

○ NO

10. Any quote subcontracted out without certificates of insurance?

○ YES

○ NO

11. Is a formal safety program in place?

○ YES

○ NO

12. Any group transportation provided?

○ YES

○ NO

13. Any volunteer, donated or leased labor?

○ YES

○ NO

14. Any employees physically challenged?

○ YES

○ NO

15. Are athletic teams sponsored?

○ YES

○ NO

16. Slip Resistant Shoe Program in Place?

17. Has “Aegis” or “No Slip” floor treatment been applied within the last 1-2 years?

○ YES

○ NO

○ YES

○ NO

18. Do you have a bulk oil handling system at each store?

○ YES

○ NO

19. Do you offer transitional return to work tasks for injured employees?

○ YES

○ NO

20. Any prior coverage declined, cancelled or non-renewed in the last 3 years?

○ YES

○ NO

21. Drug testing (pre/post/random)?

○ YES

○ NO

22. Is there any screening or background checks performed as part of hiring?

○ YES

○ NO

23. Are there cameras in the parking lots?

○ YES

○ NO

24. Is there training for robberies?

KAH Insurance Brokerage, Inc.

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Mcdonalds Workers Compensation Application

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