2022-197-E-Visitors Bureau-Valarie Schwartz-Compile Accessibility information from resturants and hotels

Browse Search

1001700 2008 137728 208 09-18-2015Page 2 of 4EA 2504.2 Rev. 07-2015 Does the applicant contemplate any change in business operations within the next year? Yes No If yes, explain. Most recent Workers Compensation insurer Company - Explain if none - If State Farm, give current status Policy Number From To Are subcontractors used? Yes No If yes, is any work sublet without certificates of insurance? Yes No If yes, explain. Is a formal safety program in operation? Yes No Does the applicant or any employee:Own, operate, pilot, charter, or lease any aircraft or watercraft? Yes No Pilot any aircraft on company business? Yes No If yes, explain: Is there any donated or volunteer labor? Yes No Is any work performed underground or above 15 feet? Yes No If yes, explain. Is any work performed on barges, vessels, docks, or bridges over water? Yes No If yes, explain. Current number of employees (excluding proprietors, partners, and officers)Full Time 0 Part-time or seasonal 0 Temporary 0 Are there any employees under 18? Yes No If yes, give names and ages: Do you lease workers from others? Yes No If yes:Temporary Full time If full time, name of leasing company Does Leasing Company provide you with a Certificate of Workers Compensation Insurance? Yes No Do you lease workers to others? Yes No If yes, explain: Does the applicant require pre-employment physicals? Yes No Is premium experience rated? Yes No Last year's modification Does the payroll shown on this application and attached documentation include the entire payroll of all employees at all locations? Yes No If no, explain. Does this risk comply with all Workers Compensation Underwriting Guide requirements? Yes No If no, explain. Does the applicant have a majority interest (greater than 50%) in any other companies? Yes No If yes, give company names, Workers Compensation carriers and policy numbers below. Proprietors, Partners, Officers If permitted by state Workers Compensation law, should executive officers, sole proprietors, general partners, limited liability company members, and stockholder-employees be included or excluded. Complete section below. Names of: Proprietors, general partners, LLC members, stockholders-employees, and executive officers. included excluded Title or relationship Ownership % Duties and type of work performed Annual payroll or remuneration Valarie Schwartz Owner 100 Business Consultant (outside of office) $7,500.00 DocuSign Envelope ID: C91CBC16-495D-4832-812B-E650985A3B1B