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Are
you working with
an CoverageRx agent |
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If
Yes, please provide their name |
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How
did you hear about CoverageRx? |
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Gross
Annual Payroll Estimates by Classification for
2000-2001 Policy Year |
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Officers to be Included/Excluded |
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Please elaborate on any Yes responses in the Remarks
section |
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Current # of permanent employees |
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Current # of temporary/seasonal employees |
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Number of W-2s filed for latest reporting period: |
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Are group medical benefits provided? |
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| If
yes, % paid by employer |
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| Is
paid vacation provided? |
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| Is
paid sick leave provided? |
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| Is
modified/alternative work available for injured
workers who are released for modified duty? |
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| Do
you require pre-hire/post-offer physicals? |
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Do you
require Pre-placement drug screening? |
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Are Alcohol/drug rehabilitation programs offered? |
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Who is in charge of the safety program? |
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How long/experience with the program? |
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Describe any safety incentive programs: |
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Do any
employees travel out of state? |
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Do you
sponsor athletic teams (for employees)? |
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Number
of employees who daily lift more than 20 lbs? |
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Number
of employees who daily lift more than 40 lbs? |
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Number
of employees who daily lift more than 60 lbs? |
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| If
you have any out of State locations, please include
them here |
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If
available, please provide the most recent
experience modification worksheet you have. |
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