Provide accurate identification and classification details for the policyholder entity. All fields marked as mandatory must be completed to ensure proper policy matching and risk assessment.
Legal Entity Name
Trade Name (DBA)
Primary Policy Number(s)
Policy Period Start Date
Policy Period End Date
Corporate Risk Officer Full Name
Risk Officer Official Title
Risk Officer Direct Email
Risk Officer Contact Phone
Primary Business Classification Code
Secondary Business Classification Codes (if applicable)
Manufacturing
Distribution
Professional Services
Construction
Healthcare
Hospitality
Retail
Technology
Transportation
Other
Business Organizational Structure
Corporation
Limited Liability Company
Partnership
Sole Proprietorship
Joint Venture
Non-Profit Organization
Government Entity
Have there been any changes to the legal entity structure during the policy period?
Has the company undergone any name changes or rebranding during this period?
Have there been significant changes to primary business operations or services offered?
Declare complete and accurate payroll data by classification. Include all employee compensation and third-party contractor disbursements. Significant variances from prior year declarations will require detailed explanation.
Total Annual Payroll (excluding contractors)
Payroll Distribution by Classification Code
Classification Code | Classification Description | Annual Payroll Amount | Number of Employees | Overtime Payroll | Bonus & Commission Payroll | |
|---|---|---|---|---|---|---|
Total Overtime Payroll (all classifications combined)
Total Bonus & Commission Payroll (all classifications combined)
Has total payroll increased or decreased by more than 15% compared to the prior policy period?
Total Third-Party Contractor Disbursements (1099 or equivalent)
Contractor Disbursements by Service Type
Service Type | Contractor Classification | Total Disbursement | Number of Contractors | Certificate of Insurance Obtained | |
|---|---|---|---|---|---|
Payroll Allocation Method Used
Actual Hours Worked by Classification
Percentage Estimation Based on Duties
Peak Season Weighted Average
Standard Split Ratio
Other Method
Do any employees split time between multiple classification codes?
Identify and quantify any changes to high-risk job classifications, operational exposures, or work environments that may impact risk assessment and premium calculation.
Have any new high-risk job classifications been added during this policy period?
Has the number of employees in existing high-risk classifications changed by more than 20%?
Has the company commenced any new operations, services, or product lines?
Have there been any new geographic exposures including international operations or remote work expansions?
Have new physical or environmental hazards been introduced to the workplace?
Has there been significant changes to work schedules including shift work, overtime hours, or seasonal patterns?
Has the company acquired new equipment, machinery, or vehicles that alter operational risk?
Were there any reportable incidents, claims, or near-miss events during this period?
Evaluate and document the organization's safety management systems, loss control initiatives, and eligibility for premium credits or discounts based on risk mitigation efforts.
Does the organization maintain a formal, written safety and health program?
Select all safety program elements currently implemented and active:
New Hire Safety Orientation
Job-Specific Training
Supervisor Safety Accountability
Safety Committee Meetings
Incident Investigation Protocol
Return-to-Work Program
Drug & Alcohol Testing
Ergonomics Assessments
Personal Protective Equipment Program
Emergency Response Plans
Hazard Communication
Regular Safety Audits
Total Annual Safety Training Hours (all employees combined)
Is there a designated safety committee or safety officer position?
Frequency of Formal Safety Inspections
Daily
Weekly
Monthly
Quarterly
Annually
As Needed Only
Rate the effectiveness of the following safety program components (1=Poor, 5=Excellent)
Poor | Fair | Average | Good | Excellent | |
|---|---|---|---|---|---|
Management Commitment | |||||
Employee Participation | |||||
Hazard Identification | |||||
Training Quality | |||||
Incident Reporting Culture | |||||
Corrective Action Follow-through |
Select all loss control credits or discounts for which the organization believes it qualifies:
Drug-Free Workplace Program
Safety Committee Credit
Pre-Employment Screening
Defensive Driving Training
Fire Safety Compliance
Health & Wellness Program
Accident Prevention Plan
Equipment Safety Devices
Security Systems
Business Continuity Plan
Upload supporting documentation for loss control credits (certificates, audit reports, program descriptions)
Have there been any modifications to the safety program during this policy period?
Total Recordable Incident Rate (TRIR) for this period
Total Annual Investment in Safety Programs & Equipment
Final verification and attestation by authorized financial leadership and independent audit confirmation. This section requires official signatures and supporting documentation to validate the accuracy of all reported data.
Chief Financial Officer Full Name
CFO Official Title
CFO Digital Signature
CFO Signature Date
Independent Auditor Firm Name
Auditor Report Date (if applicable)
I hereby certify that the payroll and exposure data reported herein has been reviewed against official company financial records and is accurate to the best of my knowledge.
I confirm that all contractor disbursements have been properly classified and reported in accordance with applicable insurance reporting standards.
I attest that the information regarding high-risk classifications and operational changes is complete and transparent.
I acknowledge that material misrepresentation or omission of facts may result in policy cancellation or premium adjustment.
Upload Audited Financial Statements or Review Report supporting the payroll figures declared
Upload General Ledger Payroll Summary or Certified Payroll Register
Were there any material audit findings related to payroll or employee classification?
By submitting this form, the undersigned certifies that all information is true, complete, and accurate. The organization agrees to notify the insurer of any material changes that occur after submission but before policy renewal.