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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
Company Name
Required
Company Owner
Required
Business Type
Optional
Personal Information
First Name
Required
Last Name
Required
E-Mail Address
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
Street
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Additional Information
Do you currently have insurance?
Required
Current Insurance Provider
Optional
Expiration Date
Optional
/ /
Nature of Business
Optional
Year Business Established
Optional
Annual Employee Payroll
Optional
Amount of Desired Insurance
Optional
Supplemental Information
Describe your hiring and screening process.
Required
What type of training program do you have for new employees and to what extent are supervisors involved?
Required
Do you have a formal return to work program?
Required
Do you have a substance abuse screening program?
Required
Do you have a formal written safety program?
Required
If so, are supervisors and employees held accountable for following the program?
Required
If the answer to either safety program question is no, please explain why.
Required
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?
Required
List the employer paid benefits & those the employee may participate in.
Required
What is the average turn over rate for employees per year?
Required
What is the average turnover rate for managers and supervisors per year?
Required
What is the average employee tenure, age range, and experience level?
Required
Number of full time employees
Required
Number of part time / seasonal employees
Required
How would you describe the overall employee relations at your company?
Required
Are the employees union or non-union?
Required
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.
Required
Has the company had any loss control services performed in the last three years?
Required
If loss control services have been performed have all recommendations been complied with?
Required
List any recommendations / changes you have made in the safety program that would improve the overall safety results.
Required
Submission Validation
Required
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Important Notice
Any 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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Whitestone Office 12-23A 150th Street | Whitestone, NY 11357 | 718-767-9226
Mattituck Office 15400 Main Rd | Mattituck, NY 11952 | 631-765-2777
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