REQUEST FOR PROPOSAL

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.

Account Executive

Legal Name

DBA Name

Email Address

Phone Number

Physical Address

City

State

Zip Code

Mailing Address

City

State

Zip Code

Entity Type

	Yes
C CORP	Yes
LLP	Yes
LLC	Yes
Partner	Yes
Sole Proprietor	Yes
Other	Yes

	Yes	No
Are there multiple Locations	Yes	No

	Name	Own %	Title
Owner/Officer	Name	Own %	Title
Owner/Officer	Name	Own %	Title
Owner/Officer	Name	Own %	Title

FEIN #

SUTA #

Type of Busniess

Years in Business

Description of Company's Core Business

Contact Name

Phone

Mobile

Fax

Email Address

Payroll Contact

Phone

Mobile

Fax

Email Address

General Insurance Information

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

Payroll Information

	Date
Pay Start Date	Date
Pay End Date	Date
Pay Day	Date
Call-In Day	Date
Pay Cycle	Date

Total Estimated Payroll

7 Day Pay Period (i.e.: Wenesday to the following Thursday or Monday to the following Sunday)

Current PEO or Payroll Service

	Yes	No
Is vacation accrued	Yes	No
If yes, Is there a written policy or formula for calculation	Yes	No
If yes, please provide a copy below	Yes	No
Do any employees have garnishments or any other payroll deductions	Yes	No

Please provide documentation for written policy or formula calculations

Employee Census

	Year	Average # of employees (Last 3 yrs)	# W2 Forms Issued (Last 3 yrs)
1	Year	Average # of employees (Last 3 yrs)	# W2 Forms Issued (Last 3 yrs)
2	Year	Average # of employees (Last 3 yrs)	# W2 Forms Issued (Last 3 yrs)
3	Year	Average # of employees (Last 3 yrs)	# W2 Forms Issued (Last 3 yrs)

Human Resources

	Yes	No
Is there any EEOC/EE related issues or litigation pending	Yes	No
If yes, provide explanation. Is there unions or attempts to create a union?	Yes	No
If yes, is there an employee handbook?	Yes	No

Explanations

Please provide a copy if there is an Employee Handbook

401(k) Plan

	Yes	No
Is there a 401(k) Plan	Yes	No
If Yes, will the plan be rolled over	Yes	No
No, Is there interest in offering 401(k) Plan to employees	Yes	No

How Old Is Plan

	Yes	No
Has Testing been Completed Each Year	Yes	No
Has it Failed	Yes	No

Workers' Compensation Data

Describe Operations

Workers Compensation Class Code & Wage Info

	State	WC Class Codes	Position/Job	# of Employees	Annual Wage
1	State	WC Class Codes	Position/Job	# of Employees	Annual Wage
2	State	WC Class Codes	Position/Job	# of Employees	Annual Wage
3	State	WC Class Codes	Position/Job	# of Employees	Annual Wage
4	State	WC Class Codes	Position/Job	# of Employees	Annual Wage
5	State	WC Class Codes	Position/Job	# of Employees	Annual Wage

Modifier to be used

Health Insurance

	Yes	No
Do you currently have a medical plan?	Yes	No
Do you currently have an Ancillary Product?	Yes	No

Renewal Date

	Numbers
Total # of Employees	Numbers
Full Time (30 Hrs or more a week)	Numbers
Part Time	Numbers
Number of employees participating* (minimum of 75% required)	Numbers
Company contribution (50% minimum of employee only premium)	Numbers

Frequency of Deductions

Fully Insured

Effective Date of Current Coverage: +

Which plans if any are employer sponsored (Employer pays 100% of premium)

The following documents must accompany the application. Provide an explanation where appropriate.

	Yes	No
Is there a written Safety policy? (If Yes, attach a copy)	Yes	No
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)	Yes	No
Attach a copy of the Workers’ Compensation declaration page.	Yes	No
Provide risk modification worksheet or sign NCCI authorization.	Yes	No
Attach a copy of the last State unemployment quarterly report or last payroll report to confirm wages. ☐Yes ☐No	Yes	No
Three years of carrier generated loss runs. If cannot be provided, provide three years of OSHA logs or client loss letter/runs.	Yes	No
Provide details of all WC claims > $25,000	Yes	No
Has there ever been an OSHA inspection? (If Yes, attach citation/abatement)	Yes	No
Drug Free Workplace policy	Yes	No

Please Attach Appropriate Documents

Explanations

NCII Authorization

I, the undersigned, duly authorized officer of the below named business, do hereby certify that our business:

	Information
Company Name	Information
Address	Information
Telephone Number	Information
FEIN #	Information

How did you hear about us? *

Authorize Covenant Services to check the above-named business modifications, worksheets, and risk snapshots through NCCI (National Council On Compensation Insurance, Inc.)

*

clear

Print Name

Title

Date +