General Information:

Company Legal Name:





Key Contact:






Year Business Began:

Brief Description of Organization:

# of full time employees:

# of part time employees:

FUTA Exempt?


# of Locations:


Owner Name: Title: % Ownership

For Health Insurance Underwriting Only: I give Merit's Broker, LMC, and Merit permission to contact any employee regarding any outstanding health information.

Employee Benefits:

Administration Fees COBRA:

Administration Fees Annual 5500

Administration Fees Other:

Retirement Planning:

Type of Plan:

Current Plan Assets (if known): $

Annual Plan Testing Fees:

Annual Administration Feed:

Annual Audit Fees:

Annual 5500 Fees:

Fiduciary Liability Insurance Cost:

Ancillary Benefits:
Short Term Disability:
Long Term Disability:
Flexible Spending Account:

Administration Costs: Section 125 Maintenance:


Annual Cost:


Annual Costs:

Other Pre-tax Benefits:

if so, what?

Any additional benefits requested by employees?

Benefits Staff:

Number of Employees:

Average pay rate:

Number of Hours Spent per Week:

Briefly describe the primary duties of these employee(s);

Human Resources:

Do you have Employment Practices Insurance (EPLI)?

Annual Premium:


Plan limits:

Do you conduct Pre-employment background checking?

Types of checks conducted:

Costs per check:

Do you conduct drug testing?


Post accident?


Reasonable suspicion?

Cost per Drug Screen?

Do you utilize Pre-employment job match testing?


Cost per test:

Do you run classified ads for open positions?

Sources used:

Cost per Ad:

What is your three year turnover %?

How often do you update your employee handbook?

Do you conduct employee engagement surveys?

What is your unemployment success rate?

How much do you typically spend on non-EPLI claim employment legal fees annually?

Human Resource Staff:

Number of Employees:

Average pay rate:

Number of Hours Spent per Week:

Briefly Describe the Primary Duties of These Employees:

Payroll and Payroll Taxes:
How are you processing payroll?


Payroll processing fee:

Report fee:

W-2 processing fee:

Tax returns:


Additional fees:

Payroll Frequency:

Do you utilize a time and attendance system?

Do you own or lease?



Do you have a HRIS system?

Do you own or lease?



Payroll and Payroll Tax Staff:

Number of Staff:

Average pay rate:

Number of Hours Spent Per Week:

Briefly describe the primary duties do these employee(s):

Workers' Compensation and Risk Management:
Is an up front premium required?


Does a year-end audit typically result in additional premium due?

Ask for the most recent audit report.

Workers' Compensation and Risk Management Staff:

Number of Employees:

Average pay rate:

Number of Hours Spent per Week:

Briefly describe the primary duties of these employees:

Risk Assessment:

Workers' Comp Provider:

Workers' Comp Experience Mod: Renewal Date:

Have you experienced any work-related injuries or other Workers' Compensation claims in the last 3 years?

Please provide details:

Who is currently responsible for work-related injury claims management?

Do you own or lease aircraft or watercraft?
Current or discontinued operations involving the storage, treatment, discharge, application, disposal or transport of hazardous materials?
Any work performed underground or over 15 feet?
Any work performed on barges, vessels, docks, or bridges over water?
Engaged in any other type of business?
Are subcontractors/independent contractors used?

If yes, what % of subcontractors without coverage?

Any work sublet without certificate of insurance?

If yes, what % of work?

Is a written safety program being utilized?
Any group transportation provided?
Any employees under 16 or over 60?
Any seasonal employees?
Any volunteer or donated labor?
Do employees travel out of state?
Any company sponsored athletic teams?
Are physicals required post employment offers?
Does your organization currently have any insurance with Zurich Financial Services?
Has any coverage been declined, canceled, or non-renewal in the past 3 years?

If yes, please describe:

Are employee health plans currently provided?

Is there labor interchange with any other organization?

Do you lease employees to and from any other employers or temp services?
Do any employees predominantly work from home?
Any tax liens or bankruptcy in the last 5 years?
Any undisputed workers' comp premium due from you or any commonly managed or owned enterprises?

If yes, entity name & policy number:

Has your organization had any employment-related lawsuits or complaints filed in the last 5 years?

If yes, please describe:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.