Workers Compensation Application
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4 New Business
RENEWAL
21 Maple Avenue • PO Box 9175 • Bay Shore, NY 11706-9175 •
Call Toll Free (800) 645-5820 • in NY (631) 666-5050 • Fax: (631) 666-5723 •
NOTE: All Questions Must Be Answered
Security Guard WORKERS’ COMPENSATION Application
(Workers’ Compensation ACORD Application Must Be Attached)
1.
NAME: _______________________________________________________________________________________
(COMPLETE NAME AS IT SHOULD APPEAR ON THE POLICY, INCLUDING INC., CORP., LTD., ETC.)
2.
Physical Address: _______________________________________________________________________________
NO.
STREET
CITY
COUNTY
STATE
ZIP
3.
Mailing Address: _______________________________________________________________________________
NO.
STREET
CITY
COUNTY
STATE
ZIP
4.
Policy proposed effective date ________________ to ______________
(12:01 A.M., Standard Time, at the address above)
5.
Phone: _________________________________________ Fax: _________________________________________
6.
Email: _________________________________________ Website: ______________________________________
7.
Person to contact: __________________________ Title: ____________________ License No.: _______________
How did you hear about us? Web surfing Ad in which publication: ______________ Other: ____________
8.
Date established: __________ Corporation Partnership Individual Other: ________________________
9.
10.
Federal ID Number: ______________________________
Bureau ID Number: ____________________________
11.
Total # of employees: ________ (Full Time: ______) (Part Time: ______) (Armed: ______) (Unarmed: _____ )
12.
Total # of guard hours billed to client(s) annually: ___________________ Number of Supervisors: ____________
Describe duties of Supervisors: ___________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
13.
Employees over age 65: ________
Full Time: ______
Part Time: ______
Detailed Description of Duties: ___________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
14.
Employees under age 21: ________
Full Time: ______
Part Time: ______
Detailed Description of Duties: ___________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Yes No
15.
a. Average length of employment _________________ b. Are guards licensed in states listed?
a. Do you anticipate using dogs? Yes No
16.
b. Number of dogs used with handlers: _______________________ c. Without handlers: _____________________
03/13 ed.
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