Please enable JavaScript in your browser to complete this form.Applicant Information:Company Name:Business Name (DBA):Legal Name: *FirstLastApplication ID:Application completed by: Broker: Employer: Please provide (first, last) name: *FirstLastDate: *Hours of operation 24 hours a.m.p.m.Any driving in excess of 11 hours per shift? Yes No Any driving in excess of 60 hours within 7-consecutive days? Yes No Total number of vehicle recoveries in the last 12 months by employees:Any contract towing? Yes No If yes – Please explain and provide the list of contracts:Does the insured perform any of the following?Vehicle repossession Yes No Recovery of vehicles transporting hazardous materials Yes No Repelling on hillsides/cliffs/canyons to retrieve vehicles Yes No Underwater recovery Yes No Low-bed/heavy hauling/transportation of large items such as construction equipment, farm equipment, oversized loads or aircraft? Yes No Percentage of towing that are from highways/freeways?%What percentage of towing is private property impounding?%(Total must equal 100%)1. What percentage of the insured’s operations involves towing of trucks that are one ton or greater; i.e. buses, RV’s or trailers?%2. What percentage involves the towing of vehicles that are less than one ton?%Percentage of work sub-contracted out:%Are certificates collected annually for sub-contractors? Yes No Total number of vehicle recoveries in the last 12 months by Independent contractors: years): If you Please explain the type of work sub-contracted out:General Classification Evaluation:1. Maximum Height exposure: N/A Ft.If applicable - Method of reaching height exposures:2. Maximum Weight lifted: N/A If applicable: Manual Lifting lbs.Please list the typical types of items lifted:Employee(s) lifts with assistance: . Please explain:3) Vehicle exposure:Total # of Tow Trucks:Number of employee drivers:Do employees take the vehicle home overnight? Yes No Driving Radius in miles:mi.GPS tracking system installed? Yes No MVR’s Checked: Yes No Company Owned: Yes No PUC Filling N/A Yes If YES:MCP Filling N/A Yes If YES:4) Any Out of State, International, or Overnight Travel: Yes No If Yes - Please provide the following details below:Number of employee’s traveling:Frequency of travel:Method of transportation:Location(s)/State(s):AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPlease select all that apply5) CPR Training provided: Yes No If Yes - Number of Employees certified:Claims Handling:1) Is there a set procedure for reporting claims? Yes No 2) Is there a formal written accident investigation report? Yes No 3) Do you currently participate in an MPN program to control claim costs? Yes No Personnel Practices:1) New-hire orientation program: Yes No Is the orientation documented? Yes No 2) Owner is active in daily operations: Yes No 3) Employee Handbook: Yes No 4) Post-accident drug testing: Yes No 5) Job specific training: Yes No 6) Performance Appraisals: Yes No 7) Wellness program in place: Yes No 8) Are any of the following benefits provided?Medical: Yes No Employer contribution:%Percentage of employees enrolled:%Retirement: Yes No Employer contribution:%Percentage of employees enrolled:%9) Any other information in regard to employee benefits? If so, please provide those details:Employer-Employee Relationship:1) Employee Turnover Rate (Annually):%Average Tenure of Employees (in # of years):2) Number of employees hired:Full Time (annual)Payroll Estimate:Part Time/Seasonal:Payroll Estimate:No. of seasonal Employees:Seasonal Employee Period From Month:JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberTo Month:JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberSafety Program/Practices which are implemented and enforced:1) Fall Protection Plan: Yes No N/A 2) Heat and illness prevention program: Yes No N/A 3) Respiratory program: Yes No N/A 4) Driver safety training plan: Yes No N/A 5) Forklift training & safety plan: Yes No N/A If Yes – Annual Certification required: Yes No N/A 6) MSDS available for all chemicals/products used: Yes No N/A 7) Written Lockout/Tag out/Block out Procedures: Yes No N/A 8) Hazardous chemicals safety plan: Yes No N/A 9) Confined spaces plan: Yes No N/A 10) Active safety incentive program for all employees: Yes No N/A 11) Are supervisors held accountable for a safe work environment? Yes No N/A 12) Is there a dedicated full time safety manager? Yes No N/A If Yes – Please provide:Name *FirstLastTitle13) Safety meetings are conducted: Daily Weekly Monthly Quarterly Does not conduct Safety Meetings Are safety meetings documented? Yes No 14) Personal Protective equipment provided to all employees: Yes No If Yes, please list types below:15) Employee to Supervisor ratio:16) What loss prevention recommendations have the insured implemented Loss control service has not been performed. Year implemented:Please explain...Machinery and Equipment:1) Types of machinery/equipment used:N/APlease list the types of machinery/equipment used:2) Are all equipment operators certified? Yes No 3) Is all machinery/equipment properly guarded: Yes No 4) Age of equipment in years: 0-5 5-10 10-20 20+ 5) Condition of the equipment: Excellent Good Average Poor 6) Who is responsible for maintaining machinery? Insured Contractor Other If Other:Is there any other information about your company, operations, or practices you have implemented which could have an impact on mitigating injuries?Submit97169
