THIS FORM IS ONLY FOR A BUSINESS LOCATED IN THE STATE OF TEXAS. IF OUTSIDE OF TEXAS, PLEASE CONTACT JAMES ZANDER DIRECTLY.
PLEASE FILL OUT COMPLETELY.
First and Last Name of Contact Phone Number Fax Number Email Address Website Address Company Name Company Address
Additional Locations
Nature of Business
Is this business a Corporation Partnership Individual Joint Venture Subchapter S Corp Not For Profit Org Is this a new venture No Yes Number of employees Proposed Effective Date Federal Tax ID Number Date Business Started Estimated Annual Payroll Estimated Annual Sales Percent of operations subcontracted (if any) Are certificates required from subcontractors Building Owner or Tenant Owner Tenant City Limits Inside Outside Construction Type Frame Veneer Joisted Masonry Light Non-Combustible Non-Combustible Masonry Non-Combustible Masonry Non-Com w/ Wind Resistive Roof Number of Stories Year Built Square Footage Is this a Multiple Occupancy Building No Yes Square Footage Lease Out (if any)
Current or Prior Carrier Information
Describe any Claims or Losses
GENERAL INFORMATION Any watercraft, docks, floats owned, hired or leased No Yes Any past/present involvement in hazardous materials No Yes Any work performed underground or above 15 feet No Yes Any work preformed on barges, vessels, docks, bridge over water No Yes Applicant engaged in any other type of business No Yes Are sub-contractors used (If yes, what %) No Yes Any work sublet without certificates of insurance No Yes Is a formal safety program in operation No Yes Any group transportation provided No Yes Any employees under 16 or over 60 years old No Yes Any seasonal employees No Yes Is there any volunteer or donated labor No Yes Any employees with physical handicaps No Yes Do employees travel out of state No Yes Are athletic teams sponsored No Yes Are physicals required after offers of employment are made No Yes Any policy of coverage declined, cancelled or non-renewed during the prior 3 years No Yes Are employee health plans provided No Yes Is there a labor interchange with any other business or subsidiaries No Yes Do you lease employees to or from other employers No Yes Do any employees predominantly work at home No Yes Any bankruptcies, tax or credit liens against the applicant in the past 5 years No Yes PLEASE ADDRESS ANY YES RESPONSES:
CENSUS Employee Name Job Title/Description Full/Part Time Annual Payroll example
Additional Employees (if needed):
How would you like us to contact you Email Phone Fax
Comments:
