Jackson Lloyd - Texas Occupational Accident Insurance

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Agent's Name:		Phone:
E-mail:		Fax:
City:		Agency:
Applicant Name:		Proposed Eff Date:

Corp. Partnership LLC Ind. FEIN Yrs in Bus:

All entities of applicant included above? Yes No

Chamber program? Yes No Chamber name:

Mailing Address:

(including city, state and zip)

Web Address:

(http://www.yourwebsite.com)

Email Address:

Locations:

Description of Operations/Exposures:

1. Does the applicant have any:

	Employees working out of their homes		Labor interchange with entities not included above
	24 hour operations		USL&H, Jones Act or FELA exposures
	Aircraft exposure		None of these

2. Does the applicant manufacture, handle, sell, or transport any of the following:

	Chemicals		Fuels
	Flammables		Hazardous Wastes
	Drugs		None of these
	Explosives

3. Does the applicant have the following in place:

	Self-Inspections for safety		Safety program
	Safety meetings		Safety director
	Employee training program		None of these
	Drug/Alcohol testing

4. Does the applicant desire a premium credit for implementation of:

	Approved ERISA plan		Approved Alternative Dispute Resolution plan
	None of these

5. Does the applicant perform any of the following operations:

	Underground/Tunneling – Max ft.
	Work at heights above 15 feet – Max ft.
	Neither of these

6. Has the applicant had:

	OSHA violations/recommendations		OSHCON inspection
	Employers Liability loss		None of these

Automobile Exposure
(Company owned vehicles, enter the number of vehicles for each type next to its appropriate radius of use)

Radius of use (miles)	Private Passenger	Light Commercial	Medium Commercial	Heavy Commercial	X-Heavy Commercial	Tractor-Trailer
0-50
51-200
Over 200
Do employees drive personal vehicles for business purposes? Yes No

Loss History –
Must provide at least the past 3 years loss history. Loss runs must be valued within the past 60 days. If no prior coverage, a statement of losses must be attached.
Loss runs attached Statement of losses attached

Current Coverage:
Carrier Limit SIR/Ded

Premium Renewal Date

Requested Coverage:
Limit SIR

Rating Information:
Owners / Executive Officers: Included Excluded

Will you have any 1099 employees working for you during this policy period? Yes No

If so, do you want to provide them with coverage under this policy? Yes No

Occupation	Class Code	F/T Employees	P/T Employees	Total in Class	Annual Payroll or Earnings
Owners / Executive Officers	8809




TOTAL:

*Please note – Payroll for each employee should be capped at $62,400. Also, overtime should be calculated on straight pay.

*Applicant will submit a copy of the most recent W-3 form upon binding.

*If 1099 employees are to be included in coverage, please submit a copy of the most recent 1099 Form issued to each employee.