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 PersonnelCurrent 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.
