Kansas Workers’ Compensation Questionnaire

1717 Hidden Creek Court

St. Louis, MO 63131

314-965-3333

800-843-2277

Fax: 314-821-0534

Contact Name:

Firm Name:

Address:

County:

Phone:______Fax: ______

Email:______Website: ______

Federal Employer ID Number:

Please mark your type of practice:  Sole-Proprietor  Partnership  P. C.  L.L.C. D/B/A:______

 Other:______

  1. Desired effective date of coverage? ______1b. How did you hear about us? ______
  1. Estimated annual remuneration of employees:

Total Payroll: $______Total Employees: ______

(Excluding Executive Officers, Sole Proprietors(Excluding Executive Officers, Sole Proprietors

Partners of the Partnership or Members of an LLC*)Partners of the Partnership or Members of an LLC*)

* Please list all Executive Officers, Sole Proprietors, Partners of the Partnership or Members of an LLC with appropriate remuneration on the graph below (use additional sheet if necessary).

Executive Officers of a Corporation: Remuneration should be computed at a maximum of $171,600 or a minimum of $44,200. Coverage may be excluded if the executive officer owns at least 10% of stock but must do so in writing (when coverage bound, form to be provided).

Members of an LLC, Partners of a Partnership or Sole Proprietors: May include himself/herselfin coverage but must do so in writing (when coverage bound, form to be provided). If including himself/herself in coverage, remuneration is computed by using $43,500 for each Member, Partner or Sole Proprietor.

Name / Coverage Option / Remuneration
Member of LLC
Partner
Sole Proprietor
Executive Officer / Included
Excluded
Member of LLC
Partner
Sole Proprietor
Executive Officer / Included
Excluded
Member of LLC
Partner
Sole Proprietor
Executive Officer / Included
Excluded
Member of LLC
Partner
Sole Proprietor
Executive Officer / Included
Excluded
  1. Does insured have only 1 business location?  Yes  No If no, list address(es) of other locations:

______

______

  1. Do you qualify for an experience modification?  Yes  No

If yes, NCCI Identification #:______Experience Mod: ___ . ___

  1. Year business established? _____ Number of Years Experience in this field? _____ Years
  1. Did the insured have any prior carriers in the past 3 years?  Yes  No If yes, complete the following:

Carrier / Policy Number / Effective Date / Expiration Date
  1. List all claims within the past five years including who, what, when, and how much (indemnity or medical) was paid.

______

  1. Please list controls (first aid, housekeeping, work station design, etc.) that have been put in place to minimize and prevent losses: ______

______

  1. Are you aware of any accidents, incidents or events that have occurred on or after the requested coverage inception date that could lead to a claim under the policy?  Yes  No If yes, please explain: ______

______

Policy automatically includes $100,000 / $500,000 / $100,000 Employers Liability Coverage. If optional limits are desired please indicate:  $500,000 / $500,000 / $500,000  $1,000,000 / $1,000,000 / $1,000,000

Please answer yes or no to each question and provide explanation when applicable.
  1. Do you have more than 50% ownership interest in any other business?
/  No  Yes, please explain:
  1. If additional ownership interest, is this business insured elsewhere?
/  No, please explain.  Yes, provide carrier and policy #:
  1. Any part time or seasonal employees? If yes, how many and describe scope of their duties.
/  No  Yes, please explain:
  1. Are any employees leased from a PEO (Professional Employment Organization)?
/  No  Yes, please explain scope of duties:
  1. Are any employees leased to other companies or businesses on a permanent or temporary basis?
/  No  Yes, please explain scope of duties:
  1. If employees are leased, is Workers' Compensation coverage provided by the leasing organization?
/  No  Yes
  1. If employees are leased, are Workers' Compensation certificates of insurance obtained?
/  No  Yes
  1. Do any of your employees travel outside of the state/country? If yes, where do they travel and how often?
/  No  Yes, please explain:
  1. Are employee workstations ergonomically designed (working postures, seating, keyboard position, monitor, work area in general)? If no, how designed?
/  No, please explain:  Yes, please explain:
  1. Are all employees provided with training/education on ergonomic issues and safety?
/  No  Yes, please explain:
  1. Do you have any volunteer or donated labor? If yes, how many and describe the scope of their duties.
/  No  Yes, please explain:
  1. Are there health and medical controls in place, such as first aid kits, emergency and disaster plans?
/  No  Yes, please explain:
  1. Does the insured own or operate any aircraft in the course of their business?
/  No  Yes, please explain:

* Please note, workers’ compensation insurance in the State of Kansas is required if your business has an annual payroll of $20,000 or more.

Preferred Billing Method:

 Full Payment  Two Payments  Three Payments  Four payments  10 Payments  EFT

(Electronic Funds Transfer)

______

Signature of Applicant Date

A faxed or emailed copy will be deemed to be an original for all purposes.

Revised January 2017Page 1

KSWC