Contact us @

 

 

 Jackson-Lloyd
1615 Judson Road
P.O. Box 187
Longview, TX 75606

Phone: (800) 657-5242

Fax: (800) 933-8662

E-mail:
tlloyd@jackson-lloyd.com

     

Jackson-Lloyd Insurance Management

Texas Occupational Accident Insurance
Application

General Information
Applicant Name:
 Are all entities of applicant included?:
Yes No
Phone:
 Company Type:
 Contact Person:
Years in operation
 Federal Employer Tax ID / SSN:
 Website Address:
Mailing Address: (street, city, state, zip)
Locations:
Description of Operations/Exposures:
Underwriting Information
1. Do underground/tunneling or work at heights over 15 feet? Yes No
If yes, please explain.
2. Have any locations that operated 24 hours a day? Yes No
3. Have any driving exposure? Yes No
4. Have any USL&H or Jones' Act or "wet" exposure? Yes No
5. Handle or store explosives, chemicals, fuels, flammables, hazardous waste, or drugs of any type? Yes No Hazard Communication(definition attached)
Yes No
If yes, please explain.
6. Any employees working out of their homes or locations other than listed above? Yes No
If yes, please explain.
7. Have a safety program and safety meetings? Yes No
8. Perform self inspections for safety? Yes No
9. Have and enforce the use of Personal Protection Equipment? Yes No
10. Provide training for employees? Yes No
11. Have a claims administrator? Yes No
Contact person:
 Phone number:
12. Have an alcohol / drug testing program? Yes No
13. Have or been threatened with an Employers Liability Loss? Yes No
If yes, please explain
14. Had any OSHA violation or recommendations? Yes No
If yes, please explain
15. Had Workers' Compensation or Occupational Accident policy canceled/non-renewed? Yes No
Company: Date: Reason:
16. Is coverage to be used in satisfying a deductible for Workers' Compensation and/or any other plan? Yes No
Previous 3 Years Coverage
Currently Have Workers' Compensation or Occupational Accident Coverage? Yes No
Rejected WC? Yes No Proposed Effective Date?
Policy Period No. of Emp. Payroll Carrier SIR / Ded. Premium Exp. Mod
Requested Coverages -Combined Single Limit-
Coverage A - Basic Employee Benefits
per occurrence
Coverage B - Employers' Liability
per occurrence
Self Insured RetentionMinimum 1,000.00
per occurrence
Optional quote without Employers Liability Coverage? Yes No
Exposure Information
* Owner / executive officer exclusion must occur at the time the application is completed.
Explanation of duties for each owner/executive officer included below.
Any labor interchange with entities not to be covered under this policy
Yes No
Donated, volunteer, leased, shared employees or sub-contractors are NOT eligible for coverage- Do not include in table below.
Occupation Class Code F/T Employees P/T Employees Total in Class Annual Payroll or Earnings
Owner/Executive 8809
Totals 0 0 0 0

By signing this application form the applicant confirms that he or she has been provided with and inspected a specimen copy of The Hartford's Occupational Accident Coverage Forms, and understands their rejection of the Texas Worker's Compensation Act status and the coverages and limitations of The Hartford's Occupational Accident Coverage Forms issued by The Hartford.

If Coverage is issued based upon information provided in this application, the applicant understands and agrees that this application shall form a part of the policy, and the statements herein shall be construed as material representations of the applicant. Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.


Authorized Name of Applicant
Phone
Fax

Authorized Signature of Applicant
Title
Date

AGENCY INFORMATION


Agency
Phone
Fax

Licensed Recording Agent
Title
Date

Agency Contact Person
E-Mail Address

The following are explanations to frequently asked questions concerning The Hartford Application:

THE LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT (LHWCA)

This act applies to workers in maritime employment other than masters or crew of vessels.

No Coverage Available.

THE JONES ACT

Also known as the Merchant Marine Act, this law and General Maritime Law apply to injuries to or death of master and crew of vessels involved in commerce on navigable bodies of water. The Jones Act applies the Federal Employers' Liability Act to these employees and requires the employee to prove negligence on the part of the employer or its employees or agents. The General Maritime Law (common law of the sea) recognizes the vessel owner's duty to provide a "seaworthy" vessel. A seaman injured because of a ship's alleged unseaworthiness may bring suit against the vessel itself ( an "in rem" suit) in addition to any negligence claim under the Jones Act.

No Coverage Available.

DEPARTMENT OF TRANSPORTATION - MINIMUM REQUIREMENTS

Client to advise if required.

HAZARD COMMUNICATION

All employers with hazardous chemicals in their workplaces must prepare and implement a written hazard communication program, and must ensure that all containers are labeled, employees are provided access to MSDSs (Material Safety Data Sheets), and an effective training program is conducted for all potentially exposed employees.

OWN CHARTER OR LEASE AIRPLANE OR PILOT

No coverage until approved. Industrial Aid Forms must be completed.

SUNSET CLAUSE

This provision stipulates that losses must be reported to us within a certain time period from the end of the policy period (as specified in the policy).

DEFINITION OF PAYROLL

Payroll means the wage or salary (including overtime) that the Employee received from the Employer during the previous month.

Payroll for owners / executive officers is included and capped at $62,400 per policy period for each owner / executive officer.

It includes:

(a) Contributions made to an IRC Section 401(K), 403(b) or 457 deferred compensation arrangement, or an executive non-qualified deferred compensation with the Employer.

(b) Bonuses, commissions and tips.

(c) Amounts contributed to fringe benefits according to a salary reduction agreement under IRC Section 125 plan.

(d) Allocated business expenses such as automobile mileage allowances, housing, clothing, tools or moving allowances.

OWNER / EXECUTIVE OFFICER EXCLUSION CANNOT BE BACKDATED

Owner / Executive Officer exclusion must occur at the time the application is completed. If excluded, the Owner / Executive Officer Exclusion Form must be completed at the time of binding.
 
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