Workers Compensation Insurance Application

Company Details

Notice: The following states cannot be written through this program: ND, OH, WA, WY.

Applicant/Insured Name:

DBA (if any):

Contact Name:

Number of Years in Business:

Mobile Phone:

Contact Email:

Website:

Mailing Address:

City:

State:

Zip:

Legal Status:

Other Legal Status

Federal Employer ID Number:

Policy Start Date

Do you have a policy with Insurance Canopy currently?

Business Information

Locations:

Rating information (please fill out for all locations above):

Rating information for clerical staff: (If applicable)

Rating information for staff that are vehicle drivers for your business: (If applicable)

Owners, partners, officers, relatives to be included or excluded from coverage:

Coverage Limits:

Nature of Business / Description of Operations

Please Describe:

General Information

Are employee health plans provided?

Yes

Do you have written employment policies, procedures, guidelines or practices regarding workplace safety?

Yes

Do you have 50% or more interest in any other business?

Yes

Please explain:

In the last five years (ten in RI) has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson related crimes?

Yes

Is the business operations closed, temporarily suspended or not expected to open within the next 30 days?

Yes

Do you provide group transportation, where five or more employees are in a vehicle at one time?

Yes

Any prior coverage declined/cancelled/non-renewed (other than for pandemic, risk class of business or carrier no longer writing) in the last three years?

Yes

N/A

Do you lease employees to or from other employers?

Yes

Do you own, operate or lease aircraft/watercraft?

Yes

Are any of your employees under 16 or over 60 years of age?

Yes

Do employees travel out of state?

Yes

Do you use volunteer labor?

Yes

Do you use sub-contractors or independent contractors in your business?

Yes

If yes, are workers comp certificates of insurance obtained from sub-contractors and/or independent contractors?

Yes

Are you a restaurant or bar owner?

Yes

For Restaurants and Bars:

Do you have any of the following: bouncers, dance floors, delivery, or 24 hour operations?

Yes

Please explain:

Do you ever have more than two entertainers?

Yes

Do you provide catering services that exceed 20% of your total gross revenue?

Yes

What percent of your annual gross sales comes from alcohol sales? (%)

Do you provide off-premesis catering?

Yes

Do you provide catering at private residences?

Yes

Do you provide delivery services?

Yes

Do you use 3rd party delivery services for all delivery? (i.e. Grubhub, Uber Eats, etc.)

Yes

Do you check the motor vehicle records of your drivers?

Yes

Does your business use motorcycles, scooters, or bicycles?

Yes

Does your business make deliveries past 11:00 PM?

Yes

Do you have drivers under the age of 19?

Yes

Do your delivery receipts exceed 60% of your total gross annual sales?

Yes

Do your deliveries exceed a 10 mile radius?

Yes

Do you have a distracted driver policy in place?

Yes

Do you use any of the following cooking methods at any location(s):

Tableside Hibachi

Yes

Solid fuel cooking equipment using charcoal, wood or coal?

Yes

Tandor?

Yes

Have you had any losses within the last 5 years?

Yes

Loss History:

Do you currently carry workers comp insurance?

Yes

Please provide a brief description of why it was not purchased previously:

I agree to the Terms & Conditions.