MOC Workers' Compensation Supplemental Application

MOC SUPPLEMENTAL APPLICATION

Maroevich, O’Shea & Coghlan Insurance Services, Inc. 44 Montgomery Street, Suite 1700, San Francisco, CA 94104 Phone 415-957-0600 Fax 415-957-0577 License # 0589960	CONTACT: WORKERS’ COMPENSATION Direct: Fax: Email:

Insured Name:

Contact Name:

Eff. Date:

Years in Business:

Website:

FEIN:

Number of Locations:

Description of Operations:

GENERAL INFORMATION:

Current No. of Employees:

Full-Time:

Part-Time:

Seasonal:

% of Employee turnover in last 12 months:

Full-Time:

Part-Time:

Employee staffing expectation over next 12 months:

Full-Time $:

Part-Time $:

Average hourly wage in Clerical Class (8810):

Full-Time $:

Part-Time $:

Average hourly wage in Sales class (8742):

Full-Time $:

Part-Time $:

Has insured every filed bankruptcy? Yes No

Union: Yes No

% Participating

BENEFITS:

Are all employees eligible? Yes No

% Paid by Employer

% of Participation

HIRING PRACTICES:

Employment Application	Yes No	Drug/substance abuse	Yes No
Reference Checks	Yes No	Audiometric Testing	Yes No
Motor Vehicle Record Check	Yes No	Pre/Post Employment Physical	Yes No
Volunteer Labor used	Yes No	Pathogenic test (i.e. lead)	Yes No
Temporary Labor used	Yes No	Orthopedic back test	Yes No

SAFETY PROGRAM:

Safety Program/IIPP compliant with SB 198	Yes No	Protective safety equipment provided	Yes No
Modified work available to employees?	Yes No	Supervisor accountability plans	Yes No
Do you have an incentive program?	Yes No	Accident investigation program	Yes No
Designated full time Safety Director	Yes No	Health & Wellness Program	Yes No
Safety meetings/training held for all EEs	Yes No