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HomeMy WebLinkAboutYoga at the Park workers comp binder.pdf 1002109 2008 138546 208 02-03-2023Page 1 of 3EA 2504 ID.3 Rev. 10-2022 State Farm Fire and Casualty Company Home Office, Bloomington, IL Workers Compensation Application Mark Hancock Agent's Name 12-1E1E Agent's Code 93-BU-J274-0 F Policy Number New Rew of Policy Number 10-16-2023 Effective Date 10-16-2024 Expiration Date Applicant NAMASTE NOOK LLC Last Name First Name Middle Name or Initial DBA Attention, In care of, subdivision, or other Mailing address Number and Street 56 E MAIN ST REXBURG City or Town ID State 83440-1926 ZIP Code madison County H Personal phone B Business phone Underwriting 1:56 E MAIN ST, REXBURG, ID, 83440-1926; Location address of all work places yoga instructors Give a detailed description of the applicant's business (i.e. work performed, processes, services, products produced, etc.) $34,800Estimated annual revenue:1Number of years as an employer in this business: LLCApplicant type: Does the insured do work in more than one state? Yes No If yes, attach separate sheet showing separate states and payroll applicable to each. Is the applicant engaged in any other type of business? Yes No Is the applicant currently covered through an assigned risk pool, fund, or plan? Yes No Bonnie Pozzi Name of person who has payroll and other financial records for the policy premium period (208) 715-0195 Telephone number Address Bonnie Pozzi Name of person to contact for inspection (208) 715-0195 Telephone number 93-2594930Federal Employer's I.D. number Unemployment I.D. number NCCI Risk I.D. number In the past 3 years, has Workers Compensation insurance been declined, canceled, or non-renewed? Yes No Other State Farm® Fire policy numbers:93-BT-J601-4 Has the applicant had any Workers Compensation accidents, injuries, or incidents, insured or not, within the last 3 years? Yes No Does the applicant contemplate any change in business operations within the next year? Yes No Most recent Workers Compensation insurer: Company (Explain if none - If State Farm, give current status)Policy number From To 1002109 2008 138546 208 02-03-2023Page 2 of 3EA 2504 ID.3 Rev. 10-2022 Are subcontractors used? Yes No Is a formal safety program in operation? Yes No Does the applicant or any employee own, operate, pilot, charter, or lease any aircraft or watercraft? Yes No Pilot any aircraft on company business? Yes No Is there any donated or volunteer labor? Yes No Is any work performed underground or above 15 feet? Yes No Is any work performed on barges, vessels, docks, or bridges over water? Yes No Current number of employees (excluding proprietors, partners, and officers)0Full Time:5Part-time or seasonal:0Temporary: Are there any employees under 18? Yes No Do you lease workers from others? Yes No Does leasing company provide you with a Certificate of Workers Compensation Insurance? Yes No Do you lease workers to others? Yes No Does the applicant require pre-employment physicals? Yes No Is premium experience rated? Yes No Last year's modification: Does the payroll shown on this application and attached documentation include the entire payroll of all employees at all locations? Yes No Does this risk comply with all Workers Compensation Underwriting Guide requirements? Yes No Does the applicant have a majority interest (greater than 50%) in any other companies? Yes No Proprietors, Partners, Officers If permitted by state Workers Compensation law, should executive officers, sole proprietors, general partners, limited liability company members, and stockholder-employees be included or excluded. Complete section below. Names of: Proprietors, general partners, LLC members, stockholders-employees, and executive officers. Title or Relationship Ownership Percent Duties and Type of Work Performed Annual Payroll and Remuneration Bonnie Pozzi Included Excluded LLC Manager 100 yoga instructer $34,800.00 Workers Compensation Describe in detail each type of work or service performed by employees USE ADDITIONAL SHEETS IF NECESSARY TO LIST ALL EMPLOYEES. •Workers Compensation Worksheet - ID Description of Activities Show the number of employees separately in each case (e.g., carpentry, plumbing, gas furnace installation, etc.) and the annual payroll Number of Employees Actual Remuneration Last 12 months Estimated Remuneration for Next Policy Period Class Code Number Class Description Number Rate Per $100 Estimated Premium Clerical Office Employees, not otherwise classified (office workers - no outside or plant work) Outside Salespersons Truck Drivers (no other duties) Other Employees (in next row(s), describe in detail each type of work or service performed) Yoga teacher 5 30 34,800 8868 1002109 2008 138546 208 02-03-2023Page 3 of 3EA 2504 ID.3 Rev. 10-2022 Employer's Liability - Limit of Liability 100,000.00 Bodily Injury by Accident $Each accident ($100,000 minimum) 100,000.00 Bodily Injury by Disease $Each employee ($100,000 minimum) 500,000.00 Bodily Injury by Disease $Policy limit ($500,000 minimum) Minimum premium $ Deposit premium $ Premium/Payment Information 10-16-2023 10:59 AM Application taken: SFPP Yes No Payment 1 Cash Check Amount Paid $ Check Number Payment 2 Cash Check Amount Paid $ Check Number Credit Card EFT Reference Number 0.00 Amount Paid $0.00 Credit from other policy $0.00 Balance Due $208.00 Total Premium $ Important Notices •Attach a copy of Social Security Report (IRS 941) and State Unemployment Compensation Report for each of the last four quarters. •Attach copies of ALL 1099's (Including Names, Work Performed and Amount Paid) and certificates of insurance from all subcontractors. •Attach a copy of Election to Reject form for each employee who rejects Workers Compensation. Coverage is not provided until this application is approved by State Farm's Underwriting Department. I (we) am applying for Workers Compensation insurance, and the statements on this application are correct. I (we) understand that unless certificates of insurance are obtained prior to work, employees of contractors or subcontractors engaged by me (us) will be considered to be my (our) employees. Final premium for the policy will be determined by audit of financial and payroll records. Remarks