Workers' Compensation Supplemental Application

Step 1 of 5

20%

Named Insured

Web Address

Insured's FEIN

CSLB License #

Contact Name and Phone Number

Inspections

Phone

Premium Audit

Phone

Claims

Phone

Prior Payroll and Premium Information

Current Year

TOTAL ANNUAL PAYROLL

Premium

Prior Year

TOTAL ANNUAL PAYROLL

Premium

Prior Year

TOTAL ANNUAL PAYROLL

Premium

Customer Profile

Please provide a detailed description of your operations

Years in Business:

Years in Industry:

% Commercial

% Residential

% Other (Explain)

Business Entity

Sole Proprietor / Individual

Partnership

Corporation

LLC

Any ownership change in the past 3 years? If so, provide details:

FOR CORPORATIONS, PLEASE IDENTIFY THE FOLLOWING OFFICER AND OWNERSHIP INFORMATION: (Note that ownership must total 100%)

President

Ownership %

Treasurer

Ownership %

Secretary

Ownership %

Other (Include Title)

Ownership %

Other (Include Title)

Ownership %

Other (Include Title)

Ownership %

For sole proprietors, if you are married, please provide spouse’s name:

For sole proprietors, are any relatives who reside in your household employed in the business?

Yes

Are you involved in “Wrap Up” or “OCIP” projects?

Yes

If yes, provide details:

If yes, what percentage of annual payroll is dedicated to a Wrap Up/OCIP project?

If yes, is the coverage for the wrap up provided by another contractor or are you providing the coverage for the project?

Another Contractor is providing coverage

I am providing coverage

Operations and Benefits

# of Employees

Full-Time

Part-Time

Seasonal

Volunteers

Average hourly wage for employees in governing class code

(Governing class is typically 0042)

Employee turnover rate over the past 12 months:

Calculate: (100) x (# of employees who left during the year / avg # of employees during the year)

Paid Sick Leave?

Yes

Paid Vacation?

Yes

Group medical provided?

Yes

Percentage of employees enrolled:

Employer contribution percentage:

Group medical insurance carrier:

Any day laborers or temporary/employee leasing?

Yes

If yes, explain:

Subcontractors used?

Yes

If yes, for what purpose?

% of work subcontracted:

Are certificates of insurance for subcontractors obtained and kept on file?

Yes

N/A

Independent contractors used?

Yes

If yes, for what purpose?

If yes, how are they paid?

1099's?

Other?

Please explain:

Out-of-state, international or overnight (within state) travel?

Yes

If yes, explain:

Frequency of driving exposure:

Daily

Weekly

Other

Radius of operations/travel:

< 10 miles

11-50 miles

50-100 miles

100+ miles

Are vehicles company owned?

Yes

# Of vehicles:

# Of drivers:

Types of vehicles:

Other than owners’ vehicles, are any vehicles taken home?

Yes

If yes, explain:

Motor Carrier Number:

Vehicle/fleet maintenance program?

Yes

Who does the servicing?

# of employees transported per vehicle:

# of vehicles used to transport employees:

Any group transportation of four (4) or more employees in one vehicle?

Yes

If yes, how?

Car

Truck

Van

Bus

Frequency of group transportation:

Daily

Weekly

Monthly

Hiring Practices – Employee Selection - Claims

Written Application?

Yes

Pre-hire or post accident drug testing?

Yes

Reference Checks?

Yes

MVR Checks?

Yes

Pre-placement Physicals?

Yes

Any employees under age 16?

Yes

Sup. To Employee ratio:

< than 5-1

5-1

6-1

7-1

> 7-1

Any Interchange of labor between two or more employers?

Yes

If yes, explain:

Do you have a formal written accident investigation process?

Yes

Are there established procedures for reporting claims?

Yes

Return To Work (light duty) Program?

Yes

Do you use a specific medical provider to treat injured employees?

Yes

Are you currently participating in your carrier’s MPN (Medical Provider Network)?

Yes

CPR training provided?

Yes

# of employees certified:

Safety Program and Work Environment

Please identify the safety director at your company - name and title:

Are owners active in daily operations?

Yes

Do you have an active written injury & illness prevention program (IIPP)?

Yes

Do you have a Heat Illness Prevention Program in place?

Yes

Are safety meetings conducted?

Yes

Are safety meetings conducted?

Yes

If yes, how often?

Daily

Weekly

Monthly

Quarterly

Active safety incentive program?

Yes

If yes, what type of incentive?

Do new employees receive safety training/orientation?

Yes

If yes, is the training?

Formal

Documented

Informal

Have you received any OSHA citations in the last 5 years?

Yes

If yes, please provide details:

Lifting exposures?

Yes

Lifting exposures?

< 25 lbs.

25-40

40+

If 40+, manual lifting or with assistance? Please explain:

Identify the types of equipment used in your operations:

Mowers

Blowers

Hedge Trimmers

String Trimmers

Chippers

Trenchers

Stump Cutters

Loaders

Bobcats

Boom Lifts

Cranes

Cherry Pickers

Condition of equipment?

New

Good

Average

Are all equipment operators trained/ certified?

Yes

Personal protection equipment (PPE) provided by employer?

Yes

What types of PPE?

Is there strict enforcement of PPE utilization?

Yes

Landscaping Risk Exposures

Indicate % of work is conducted in each of the following operations (must equal 100% for each):

Maintenance

Construction / Installation

Other (please identify)

If you do construction/installation, what percentage is new construction?

What percentage is remodel?

What % of your labor involves hardscaping?

What is the maximum height (feet off the ground) at which you will work?

What equipment is used?

Ladder

Scaffolding

Scissor Lifts

N/A

What specific tasks are completed while using ladders/scaffolding/lifts?

Do you have a Written Fall Protection Program?

Yes

Any highway or median work conducted?

Yes

If yes, percentage of payroll?

If yes, please provide details (residential? speed zones; traffic volume; safety precautions, etc.):

Any use of pesticides/herbicides requiring licensing?

Yes

If yes, please provide details:

During the next year, do you project completing any of the following types of work?

Trenching deeper than 5 feet?

Yes

If yes, Explain:

Excavation work?

Yes

If yes, Explain:

Fire prevention services including weed abatement, brush management, debris removal?

Yes

If yes, please provide details:

Reforestation or habitat restoration?

Yes

If yes, Explain:

Removal of parasitic vines or mistletoe?

Yes

If yes, Explain:

Set-up of holiday decorations?

Yes

If yes, Explain:

Snow removal operations?

Yes

If yes, Explain:

Installation of artificial turf?

Yes

If yes, Explain:

Installation or removal of boulders greater than 50 pounds?

Yes

If yes, Explain:

Installation or removal of trees greater than 15 gals?

Yes

If yes, Explain:

Installation of sprinkler systems (other than repair work)?

Yes

Sod installation (other than minor repairs)?

Yes

If yes, Explain:

Sod installation (other than minor repairs)?

Yes

If yes, Explain:

Tree Trimming Risk Exposures

Does your operation include tree trimming (other than ground-level pole pruning)?

Yes

If yes, percentage of payroll?

What is the maximum height of tree trimming operations?

Percentage of work performed on trees 25 feet to 50 feet:

Percentage of work performed on trees above 50 feet:

Any climbing?

Yes

Maximum Climbing Height:

Number of tree climbers:

Number of ISA Certified Arborists:

Number of TCIA Tree Care Specialists:

Identify trade association affiliations:

International Society of Arborists

Tree Care Industry Association

Other:

If Other, Please Explain:

Additional Explanations / Comments

Please use this space to clarify any answers given, or to provide information regarding other relevant information about your company. This may include changes in your payroll over the years; newly implemented safety programs; details of large or complicated claims; discontinued operations; etc.

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About the LCIS Workers' Compensation Supplemental Application Form

In order to keep your Workers' Comp records up to date, please complete the form on this page.

To make this process as convenient for you as possible, we are providing a number of options to provide us with this form.

How to Request a Certificate

There are a number of ways you can submit your request:

Online: Complete the form on this page and click the submit button.

Fax or Mail: If you prefer to fax or mail us the form, click the PDF icon below and a form will download for you to complete.

You can enter your information into the form, after which we suggest you save the completed form for safekeeping. You can then print it and either fax it to (559) 650-3558

Mail the completed form to Workers' Compensation Department
Landscape Contractors Insurance Services, Inc.
1835 N. Fine Ave
Fresno CA 93727

Questions or concerns?
Call us at (800) 628-8735 or send us an email

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Landscape Contractors Insurance Services, Inc.
A Division of World
1835 N. Fine Ave, Fresno CA 93727
Tel (800) 628-8735 Fax (559) 650-3558
CA LIC # 0755906

800-628-8735