Supplemental Application

The Contractor’s Supplemental Application for Workers Compensation is to be completed with Acord 130 application. Fill out below, or download the paper application and submit to Tammy King at TammyK@alagc.org.

Supplemental Application

Business Name*
Website URL*
AGC Member?*
- Yes
- No
Business Start Date*
MM slash DD slash YYYY
Untitled
If a start-up business, who was your previous employer(s)?
Previous roles/positions:
Years of Experience in Industry
Key Personnel
Current General Liability Carrier*
Current Surety*
Current Year Projection: Estimated Annual Revenue*
Current Year Projection: Number of Employees*
5 Year Projection: Estimated Annual Revenue*
5 Year Projection: Number of Employees*
Please describe your operations/business.
Anticipated Clients & Territory (outside Alabama)*
Is your company licensed as:*
- General Contractor
- Specialty Contractor
- Subcontractor
In which states?*
What percentage of your work is Commercial?*
What percentage of your work is Residential?*
What percentage of your work is Industrial?*
What percentage of your operations is New Construction?*
What percentage of your operations is Renovation/Remodeling?*
What percentage of your operations is Service/Repair?*
What percentage of your operations is Maintenance?*
What percentage of your operations is "Other"?*
Percent of work subcontracted:
Estimated annual subcontractor costs:*
Types of work subcontracted:*
Do you require certificates of insurance and additional insured endorsement from subcontractors?*
- Yes
- No
Does your work require USL&H or FELA coverage?*
- Yes
- No
If yes, which?
Who is responsible for human resources at your company?
First Last
What pre-employment practices do you utilize in hiring personnel?*
Check all that apply.
- Application
- Drug Screens
- Reference Checks
- Skills/Trade Assessment
- MVR
- Other
Post hire, which of the following do you perform or offer?*
Check all that apply.
- Skills/Trade Training
- Health Insurance
- Exit Interviews
- Medical Questionnaire
- Disability Insurance
- Employee Manual/Orientation
- Wellness Program
- Periodic Job Reviews
Do you employee any workers under the age of 19?*
- Yes
- No
Do you employee any workers over the age of 65?*
- Yes
- No
Do you utilize workers provided by temporary staffing/leasing agencies?*
- Yes
- No
What training do you provide to temporary workers?
Does your company need safety materials and training resources in languages other than English?*
- Yes
- No
In what languages?
Person responsible for Field Operations:*
First Last
Do you have supervision on site at all times work is performed?*
- Yes
- No
Person responsible for Safety*
First Last
If this person has other roles besides implementing safety programs, what are their additional roles?
Is this person certified CPR/First Aid?*
- Yes
- No
Defibrillators on each site?*
- Yes
- No
Is a copy of Safety Plan provided to, reviewed, signed by, and filed for each employee?*
- Yes
- No
Please indicate any type(s) of drug testing required of employees.*
- Monthly
- Weekly
- Daily
- None
Does your safety plan address business driving, including smart phone and texting policy?*
- Yes
- No
Please provide any additional information.

Strengthen Your Business with Alabama AGC

Join Now

Physical Address 5000 Grantswood Road
Irondale, AL 35210

Mailing Address P.O. Box 102066
Irondale, AL 35210

Phone 205.451.1400

Fax 205.451.1499

Email admin@alagc.org

Mobile App Privacy Policy