Contractor's Supplemental Application
Workers Compensation

(To be completed with Acord 130 Application)

Fill out below, or download HERE and fax to Tammy King at

AGC Member *
Business Start Date *
Business Start Date
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: *
Check all that apply
Post hire, which of the following do you perform or offer? *
Do you employee any workers under the age of 19? *
Do you employee any workers over the age of 65? *
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 this person certified CPR/First Aid? *
Defibrillators on each site? *
Is a copy of Safety Plan provided to, reviewed, signed, and filed for each employee? *
Please check any type(s) of drug testing required of employees: *
Does your safety plan address business driving, including smart phone and texting policy? *