[PDF] STORES – RETAIL SUPPLEMENTAL APPLICATION GENERAL





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STORES – RETAIL SUPPLEMENTAL APPLICATION GENERAL

Website: Agency/Broker: GENERAL SAFETY/LOSS CONTROL Does the insured have employees who perform pick-up or delivery? ... 99 Cent or Discount Store.





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STORES - RETAIL

SUPPLEMENTAL APPLICATION Insurance Company of the West | Explorer Insurance Company | VerTerra Insurance Company

www.icwgroup.com | 800.877.1111 Named Insured:

Effective Date: Website:

Agency/Broker: GENERAL SAFETY/LOSS CONTROL

1.Does the insured have a formal safety program: Yes No 2.Does the insured have a full-time Safety Director on staff with no additional duties? Yes No If yes, individuals Name: Title:3.Return to Work Program in place: Formal Informal None

4.Insured does pre-hire and post-accident drug testing: Yes No 5.Formal Accident Investigation Program in place: Yes No 6.MVR checks done pre-hire & annually: Yes No No driving exposures

7.Number of employees is: Increasing Decreasing Stable

8.Does the insured have more than 50 employees in a building that is 4 stories or greater? Yes No 9.How many years has the insured had Workers' Compensation insurance͗10.Health benefits provided: Yes No If yes, % of employee participation: % й of employer's contribution͗ % STORES - RETAIL OPERATIONS1.Does the insured have employees who perform pick-up or delivery? Yes No

If yes, what is the maximum pick-up or delivery radius?

How many delivery vehicles, including employee o

wned, are used in the class related to Stores -

Wholesale?

Does the insured participate in any program where they are notified if one of their drivers receives a

vehicle violation? Yes No2.Does the insured have any repackaging or assembly operations? Yes No 3.What is the maximum weight of any single product?

STORES - RETAIL

SUPPLEMENTAL APPLICATION Insurance Company of the West | Explorer Insurance Company | VerTerra Insurance Company

www.icwgroup.com | 800.877.1111 4.Store hours: 24 hours 24 hours Monday

Tuesday

Wednesday 24 hours Thursday 24 hours Friday 24 hours Saturday 24 hours Sunday to

7.What type of Retail Store does the insured operate: Adult Entertainment Store Appliance Store Auctioneers Beauty Supply Store Camera Store Card/Novelty Store Christmas Tree Lot Delivery Service Only Durable Medical Supply/Equipment Store Floor Covering Store Golf Pro Shop - No Golf Lessons Hay and Feed Store Mattress Store Mobile Catering/Gourmet Food Truck/Meals on Wheels On-Line Catalog/Cyber Store Party Supply Rental Pet Stores Piano or Organ Sales Postal Substation (The UPS Store) Shopping Cart Retrieval Sporting Goods Store Thrift Store Water Delivery Service 99 Cent or Discount Store

Antique Store

Art & Craft Supply Store

Baker Store

Book/Video/Audio/Software Store

Candy Store

Cell Phone Store

Coin Operated Laundry

Dry Cleaning Collection & Distribution only

Excursion Tour Provider

Game/Hobby Store

Gun Shop

Kitchen Utensil Store

Mobile Kiosk Operations

Musical Instruments (no Organs or Pianos)

Paint or Wallpaper Store

Pawn Shops

Pharmacy

Pool or Spa Supply Store

School Supply Store

Skycaps or Baggage Handlers

Swap Meet/Flea Market

Tobacco Store

Wine, Beer or Liquor Store Other:

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