Thank you for trusting us with the following information about your company.  This information is used to evaluate your needs allowing us to tailor solutions to your business.  All information received will be held in the strictest confidence. However, this information may be released to certain suppliers for underwriting purposes.

Entity Type
Sole Proprietor
Are there multiple Locations
 NameOwn %Title

General Insurance Information

Current General Liability Carrier
Current Auto Liability Carrier
Current Group Healthy Carrier
Current Workers Comp Carrier
Current EPLI Carrier

Payroll Information

Pay Start Date
Pay End Date
Pay Day
Call-In Day
Pay Cycle
7 Day Pay Period (i.e.: Wenesday to the following Thursday or Monday to the following Sunday) 
Is vacation accrued
If yes, Is there a written policy or formula for calculation
If yes, please provide a copy below
Do any employees have garnishments or any other payroll deductions

Employee Census

 YearAverage # of employees (Last 3 yrs)# W2 Forms Issued (Last 3 yrs)

Human Resources

Is there any EEOC/EE related issues or litigation pending
If yes, provide explanation. Is there unions or attempts to create a union?
If yes, is there an employee handbook?

401(k) Plan

Is there a 401(k) Plan
If Yes, will the plan be rolled over
No, Is there interest in offering 401(k) Plan to employees
Has Testing been Completed Each Year
Has it Failed

Workers' Compensation Data

Workers Compensation Class Code & Wage Info
 StateWC Class CodesPosition/Job# of EmployeesAnnual Wage

Health Insurance

Do you currently have a medical plan?
Do you currently have an Ancillary Product?
Total # of Employees
Full Time (30 Hrs or more a week)
Part Time
Number of employees participating* (minimum of 75% required)
Company contribution (50% minimum of employee only premium)
The following documents must accompany the application. Provide an explanation where appropriate.
Is there a written Safety policy? (If Yes, attach a copy)
Are pre/post-employment background investigations performed on new hires for high hazard jobs? (If yes, attach a copy of the program or policy explaining the program)
Attach a copy of the Workers’ Compensation declaration page.
Provide risk modification worksheet or sign NCCI authorization.
Attach a copy of the last State unemployment quarterly report or last payroll report to confirm wages. ☐Yes ☐No
Three years of carrier generated loss runs. If cannot be provided, provide three years of OSHA logs or client loss letter/runs.
Provide details of all WC claims > $25,000
Has there ever been an OSHA inspection? (If Yes, attach citation/abatement)
Drug Free Workplace policy

NCII Authorization

I, the undersigned, duly authorized officer of the below named business, do hereby certify that our business:
Company Name
Telephone Number
Authorize Covenant Services to check the above-named business modifications, worksheets, and risk snapshots through NCCI (National Council On Compensation Insurance, Inc.)
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