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[Printable
Version of this Form]
Detailed description of operations: (Please send corporate
brochure)
1. Insured is a (please
check one):
____Temporary
Employment Agency ____Employee Leasing Company
2. Is the Temporary
Employment Agency/Leasing Company certified?
Yes ____ No ____ Where
Certified? ______________________________________
3. Is the company required
to file a bond with Division of Taxation pursuant to
R. I. Gen. Laws § 5-7-3? Yes____ No____
If so, name of the
bonding company _________________________________
4. A. How long has the
principal been in the industry? ____
B. Name of prior temporary employment agency/leasing company principals
have been employed by and in what capacity?
1)
_________________________________
2) _________________________________
3) _________________________________
4) _________________________________
5. Where are RI based
workers hired? _________________________________
6. Where are payroll records
for temporary/leased employees maintained?
__________________________________________________________________
7. Does the Insured maintain
separate payroll records by client/employee classification?
Yes ____ No ____
8. Does the insured
prescreen potential employees?
Yes ____ No ____
If Yes, explain process:
_____________________________________________________________________________
________________________________________________________________________________________________
9. Number of employees:
Total ________
Complete Below:
First Shift ________ Second Shift ________ Third Shift ________
10. What industries are
targeted?
1)____________________2)___________________3)____________________4)____________________
5)____________________6)___________________7)____________________8)____________________
11. Does the sales force
conduct prescreening of potential clients?
Yes ____ No ____
If Yes, what is gathered?
___________________________________________________________________________
_______________________________________________________________________________________________
12. Is it verified if the
client has a formal safety program?
Yes ____ No ____
13. Are safety checks made
periodically, by the insured, to ensure a formal safety program is still in
place and being followed? Yes ____ No ____ With what
frequency ______ What is action taken if no formal safety program is
currently in place?
________________________________________________________________________________
14.
A. Do clients sign contracts outlining, in detail, what tasks will be done
by the employee?
Yes ____ No ____
B. Is this confirmed after the assignment has started?
Yes ____ No ____
Specific to the Insured's
Internal Operations
15. Return to work program
in place and implemented?
Yes ____ No ____
If Yes,
describe: Informal / Case by Case ____ Formal Documented ____
16. Safety program in
place:
Yes ____ No ____
If Yes,
describe: Informal ____ Formal / Documented ____
_______________________________________________________________________________
Corporate Officer
Signature Printed Officer
Name Officer
Title Date
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