Alternative Resource Management

Mar 10, 10

Alternative Resource Management
Contact Info

Telephone:

361-779-5247
Fax:

210-568-4552
Click to E-Mail Us

Contact name:

Company name:

DBA:

Address 1:

Address 2:

City:

State:

Zip Code:

Country:

Phone:

Fax:

Web Site URL:

FEIN:

Type of Entity:

SIC Code:

Description of operations:

Years in business:

Other locations:

Please provide a brief overview of why you are looking to change providers:

What is your timeline for making a decision?:

Type of coverage requested:
Worker's Comp General Liability Commercial Auto Other

If "other", what type(s) of coverage:

Current payroll processed by:
In House Payroll Co. Leasing Co. (PEO)

Payroll or Leasing Co.:

Pay Cycle:
Weekly Bi-Weekly Monthly Semi-Monthly

Pay:
Hourly Salary Piecemeal

Number of owners:

Payroll Information

# of Employees	Description	Workers' Comp Classification	Annual Payroll

Vehicle info (needed if requesting commercial auto)

Make/Model/Year	VIN	Appx Value

Has the company ever had a current or past employee file a charge of descrimination, a wage and hour claim or any complaint against the company or with a government acency?:
Yes No

Explanation:

Does the applicant own, operate, or lease aircraft/watercraft?:
Yes No

Explanation:

Do operations involve storage, treating, discharging, applying, disposing, or transporting of hazardous materials?:
Yes No

Explanation:

Is any work performed underground or above 15 ft. (2 stories)?:
Yes No

Explanation:

Is any work performed on barges, vessels, docks, bridges, over water, long shoremen, or in a harbor facility?:
Yes No

Explanation:

Is applicant involved in other business?:
Yes No

Explanation:

Are SUB-CONTRACTORS used? If yes, please describe number of subs, percentage of subs and type of work by subs in explanation area.:
Yes No

Explanation:

Is work sub-let without certificates of Insurance?:
Yes No

Explanation:

Is a formal Safety-Program currently in place?:
Yes No

Explanation:

Is any group transportation provided?:
Yes No

Explanation:

Is a Drug-Free Work policy currently in place? If NO, would you implement one?:
Yes No

Explanation:

Does the company have any FAA or DOT drug testing requirements?:
Yes No

Explanation:

Are any employees under 18 years of age?:
Yes No

Explanation:

Are any employees part-time or seasonal employees?:
Yes No

Explanation:

Is there any volunteer or donated labor?:
Yes No

Explanation:

Do employees travel out of state?:
Yes No

Explanation:

Are pre-employment physicals required?:
Yes No

Explanation:

Does company bid or work on any government contracts?:
Yes No

Explanation:

Does the company provide transportation of employees to and from work?:
Yes No

Explanation:

Does the company sponsor any sports teams?:
Yes No

Explanation:

Does the company operate or perform work for a railroad?:
Yes No

Explanation:

Does the company sponsor a 401(K) or other form of profit sharing or pension plan?:
Yes No

Explanation:

Does the company have employees who work more than 40 hours a week? If yes are they paid overtime?:
Yes No

Explanation:

Are there any prior workers' compensation insurance coverage declined, cancelled or non-renewed? (last 3 years)? :
Yes No

Explanation:

Are any operations in another state? If so what states?:
Yes No

Explanation:

Are union workers or employees covered under a collective bargaining agreement employed?:
Yes No

Explanation:

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