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Workers' Comp Questionnaire <br />MAATR <br />Ii <br />4neSJUrce <br />A Vensure Empioyer Services Company <br />-Please explain all items answered yes in detail in the space below question*'F* <br />1. Do you own, operate or lease aircraft/watercraft that is used within the scope of your f <br />business operations? <br />❑Yes ZNo <br />2. Any present operations which involve exposure to chemicals or hazardous materials? <br />❑Yes RINo <br />3. Any work performed on barges, vessels, docks or bridges over water? I <br />❑Yes ZNo <br />4. Any work performed underground or higher than 15 feet above ground level? <br />❑Yes Ft/]No <br />5. Does employee turnover exceed 25% annually? <br />� ❑Yes <br />ENO <br />6. Any part time or seasonal employees? <br />❑Yes FPI]No <br />7. Any employees under 16 or over 60 years of age? <br />E]Yes ENO <br />8. Is there any volunteered or donated labor? <br />❑Yes ENO <br />_ <br />9. Do employees travel out of state or out of country? If so, scope of travel? <br />❑Yes ENO <br />10. Is there driving exposure involved within the scope of your operations? <br />❑Yes ENO—— <br />11. MVRs checked on all drivers? <br />❑Yes <br />ENO <br />12. Does the radius of operations of vehicles exceed 200 miles? <br />❑Yes ZNo <br />13. Any group transportation provided? <br />F]Yes ENO <br />14. Is a formal safety program in operation? <br />❑Yes FV]No <br />15. Is a drug -testing program in operation? <br />Yes FV <br />16. Is an early return/light duty program in operation? <br />J ❑Yes 2]No <br />17. Are subcontractors and/or independent contractors used?10 <br />Yes �d No <br />18. Any work sublet without certificates of insurance collected? <br />❑Yes ENO <br />19. Any prior coverage declined, cancelled or non -renewed in the past three years? <br />E ❑Yes ZNo <br />20. Do you maintain a GC, CBC or other contractor's license? <br />I Dyes ENO <br />21. Are employee health plans provided? <br />f ❑Yes [?]No <br />22. Is there a labor interchange with any other business/subsidiary? <br /># ❑Yes <br />ZNo <br />Signature of Person Completing Form: Date: 03/02/2022 <br />I ATTEST THAT ALL INFORMATION SUBMITTED IN THIS DISCLAIMER QUESTIONNAIRE IS TRUE AND ACCURATE. <br />MOSFORM-FULLPEOENROLLMENTPACK 29 @2020 MatrixOneSource <br />