Contractor's Supplemental Application

Workers' Compensation
(To be completed with Acord 130 Application)

AGC Member *
Business Start Date
Business Start Date
Agent Phone Number *
Agent Phone Number
Estimated annual revenue
Is your company licensed as *
Please provide a percentage for each
Please provide a percentage for each
Do you require Certificates of Insurance and Additional Insured Endorsement from subcontractors? *
Does your work require USL&H or FELA coverage? *
What pre-employment practices do you utilize in hiring personnel? *
Do you utilize workers provided by temporary staffing/leasing agencies? *
Does your company need safety materials and training resources in languages other than English? *
Do you have supervision on site at all times work is performed? *
If yes, explain
Is a copy of the safey plan provided to, reviewed, signed and filed for each employee? *
How often are toolbox meetings held? *
Please check any type(s) of drug testing required of employees
Does your safety plan address business driving, including smart phone and texting policy? *

Please send any additional materials to Marilyn Leiker at