Workers Compensation - Physical

Acct # /
800.423.7099
www.upfro.com
Date:
Insured:
Address:
Policy # / ** / Date Inspected: / ID

WORKERS COMPENSATION TELEPHONE REPORT

INSURED IS: INDIVIDUAL PARTNER CORPORATION

CORPORATE OFFICERS OR PARTNERS / TITLES / DUTIES
LENGTH OF TIME IN BUSINESS: / YEARS
PREVIOUS EXPERIENCE:
(If less than 5 years)

OPERATIONS:

WORKERS COMPENSATION TELEPHONE REPORT

JOB TITLE / NO. OF EMPLOYEES / DUTIES / PAYROLL
DESCRIBE
· Does insured do any Snow Plowing? / NO YES
· Does insured use any Incidental Help? / NO YES
· Does insured Subcontract any work? / NO YES
· Are insurance Certificates maintained on file? / NO YES
· Does insured Operate from his/her Home? / NO YES
· Any Chemicals made, used, or stored? / NO YES
· Any possible Occupational Disease Exposure learned? / NO YES
· Does the insured use Power Equipment? / NO YES
· Any Heavy Equipment used? Owned or rented? / NO YES
· Any Past Losses learned? / NO YES
· Any Additional Info or Comments? / NO YES

Additional Comments

Telephone Number / Agency Number
Policy Holder
Date / Time / Results / Remarks
Agency
Date / Time / Results / Remarks
- We have been unsuccessful in contacting the policyholder or applicant. Please advise any further handling.

Note

Conclusions are not to be drawn that there are no other hazards or unsafe conditions. Also we do not imply that all Federal, State or other political subdivision Safety Standards and/ or Regulations have been met. Furthermore, we cannot assume any responsibility or legal liability from misinformation given our representative or for any consequential damages resulting from inaccuracies, human error or delays, for whatever reason in reporting unusual conditions to you.

Report made from observation and interview and concerns such conditions and practices as were observed and considered at the time of call. It is not intended to indicate that there are no other exposures. We do not assume a legal liability due to misinformation given by the inspector, nor inaccuracies or human error. Answers to questions and narrative remarks based only on statements of informants available at time of inquiry and not on public records, searches, verifications, etc., unless where specifically otherwise stated in answers or remarks.