P.O. Box 2944 Parker, Colorado 80134 Ph: (303) 841-8999 Fx: (303) 380-1250 email: greenpointinsurance@yahoo.

com

WORKERS COMPENSATION INSURANCE

Applicant Name (LLC/Corp) Dba (if any) FEIN # Mailing address Contact Person Phone Email Effective Date Requested

Names of all Owners, Members, or Officers

Title

Last 4 digits of SS#

% Ownership

Include or Exclude from Coverage

Active or Silent Member?

1. 2. 3. 4. 5. 6. 7. 8. **Owners of less than 10% are required to have coverage unless they are a silent partner and inactive in the business.

Location #1 address:__________________________________________________________________________ Employee or Uninsured Contractor Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Annual Salary

(if hourly, determine pay over one year)

Employee Type**: Dispensary, Grow, or Infused Products

Employee or Subcontractor (1099 etc)

**If an employee works at both the dispensary & grow, count them as a grow employee **If an employee works at both the dispensary & infused products, count them as an infused products employee.

Location #2 address:___________________________________________________________________________ Employee or Uninsured Contractor Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Annual Salary

(if hourly, determine pay over one year)

Employee Type**: Dispensary, Grow, or Infused Products

Employee or Subcontractor (1099 etc)

Location #3 address:____________________________________________________________________________ Employee or Uninsured Contractor Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Annual Salary

(if hourly, determine pay over one year)

Employee Type**: Dispensary, Grow, or Infused Products

Employee or Subcontractor (1099 etc)

Location #4 address:____________________________________________________________________________ Employee or Uninsured Contractor Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Annual Salary

(if hourly, determine pay over one year)

Employee Type**: Dispensary, Grow, or Infused Products

Employee or Subcontractor (1099 etc)

**If an employee works at both the dispensary & grow, count them as a grow employee **If an employee works at both the dispensary & infused products, count them as an infused products employee.

Location #5 address:____________________________________________________________________________ Employee or Uninsured Contractor Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Annual Salary

(if hourly, please determine pay over one year)

Employee Type**: Dispensary, Grow, or Infused Products

Employee or Subcontractor (1099 etc)

**If an employee works at both the dispensary & grow, count them as a grow employee **If an employee works at both the dispensary & infused products, count them as an infused products employee.

QUESTIONS: Do you currently have a workers compensation policy for this business? If No, did you have a policy in the past that is now canceled? Yes Yes No No Not applicable

Not applicable

Have you had any workers comp claims on a previous or current policy for this business? Circle one: Yes No Not applicable Have you had any unreported employee injuries at this business? If yes, please provide details. Yes No Not applicable

Is this organization owned by another entity or parent?

Yes

No

If YES, what is the name of the parent or entity that owns this corporation as well as the parents FEIN?

Are owners engaged in any other type of business that they personally own? (if yes, what is it)

Are 1099 subcontractors used? Circle one:

Yes

No

(if yes, for what)

See info below re: definition of 1099 employees. Remember that they need to be included in coverage if they do not fit the criteria of an independent contractor. Are Independent Contractors used at your business, i.e. construction, plumbing, electrical ? Yes No (if yes, for what)

Subcontractors and independent contractors should carry their own insurance. Do you request a Certificate of Insurance as proof of coverage? Circle one: Yes No Not applicable If they do not carry liability or work comp insurance, you may be liable for their coverage or injuries. Do you utilize the services of a Professional Employer Organization or Employee Leasing Company? Circle one: Yes No If YES, what is their company name?

Does your business have a Cost Containment Certificate?

Yes

No

Did you purchase this business from another entity? If yes, indicate the former entity name.

Is a safety program in operation for employees? (manual, training, or both?)

Are there any part-time or seasonal employees? (if yes, for what)

Is there any volunteer or donated labor? (if yes, for what)

Have any of the owners filed bankruptcy? If so, was it discharged - and when?

Have the owners had workers comp insurance with Pinnacol Assurance at any time before?

*Please note that according to the State of Colorado, a 1099 employee should fulfill certain criteria in order to be EXCLUDED from coverage on your policy. If they do not fit this criteria, you should include these individuals in your policy. 1. 2. 3. 4. 5. 6. 7. 8. 9. Has his/her own business Has no employees/workers Has a business name Carries active business insurance and can provide Certificate as proof Uses own tools There is a written contract for services in place Sends you an invoice for services Is free of direction and control, other than confirming contract obligations are met You dont supervise the independent contractor