Applicant name *

Quote number *

Applicant provides employees for: *

How long has the owner(s) been in the industry? *

Are there other temporary staffing agencies operating at the same client premises? *

If yes, please provide the name *

Is there common ownership between the applicant and any other company? *

If yes, please complete an ERM-14 documenting the common ownership.

ERM-14 Upload *

Click or drag a file to this area to upload.

List all corporate officers, owners, and/or mangers of the applicant and provide officer/owner/manager name, title, and ownership percentage. *

In the last 3 years, have any of the officers, owners, or managers had any ownership in or worked for any other temporary staffing agency? *

If yes, please provide officer/owner/manager name, position, and year. *

Where are payroll records for applicant maintained? *

Is applicant maintaining payrolls by client and employee classification? *

Does the applicant verify the client has a formal safety program? *

Do clients sign contracts detailing what tasks will be performed by the employees? *

How often are visits made to client locations? *

Does applicant have a return-to-work program? *

If yes, please provide.

Click or drag a file to this area to upload.

Does applicant have a written safety program? *

If yes, please provide.

Click or drag a file to this area to upload.

Do you have operations/clients in other states? *

If yes, please provide proof of coverage for that state. *

Click or drag a file to this area to upload.

Please provide the website URL for your staffing company: *

Temporary staffing: Please submit a temporary staffing information form for each client.

Policyholder signature *

Clear Signature

Your email *

Date *

Temporary Staffing Supplemental Information Form