USL&H Application
The supplemental information is required in order for us to provide you with a quote. If you do not wish to complete our online form please use the contact us link and someone will reach out to you and gather the information over the phone.
Company Information
Business Type
Personal Information
State / Province *
Additional Information
Do you currently have insurance? *
Expiration Date
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Supplemental Information
Describe your hiring and screening process. *
What type of training program do you have for new employees and to what extent are supervisors involved? *
Do you have a formal return to work program? *
Do you have a substance abuse screening program? *
Do you have a formal written safety program? *
If so, are supervisors and employees held accountable for following the program? *
If the answer to either safety program question is no, please explain why. *
Is management committed to safety and portray a positive attitude and will work with our Loss Control Consultants complying with recommendations to create a safe work place? *
List the employer paid benefits & those the employee may participate in. *
Are the employees union or non-union? *
Have there been any critical events such as change of ownership, management turnover, reorganization, layoffs, bankruptcy etc in the last three years? If so, please describe the applicable details. *
Has the company had any loss control services performed in the last three years? *
If loss control services have been performed have all recommendations been complied with? *
List any recommendations / changes you have made in the safety program that would improve the overall safety results. *
Important NoticeAny
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
contact us. Per the terms of our
online privacy policy we will not resell your information to any third-party.
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