MCS Online :: Self Storage Program Application

About MCS Universe Of Services Resource Group Strategic Partnerships Alante Programs Online Applications

Online Applications

Self Storage Program Application

Please fill in the following application completely and click "Submit Application" below.

Named Insured(s) including DBAs

Corporation Partnership Sole Proprietor LLC Other

Named Insured FEIN

Location Addresses

1
2

add another

Mailing Address (if different from location)

Contact Name

Telephone

Fax

Business Website

Year Business was Established or Acquired by Current Owner

Current Insurance Carrier

Policy Expiration Date

Owners, Partners, Officers, Managers, Relatives to be included or excluded from policy

Name	Title	% of Ownership

Include Exclude

add another

Estimated Payroll Under Class Codes

Class Code 8290 - Payroll dollar total for all self storage employees, including on-site managers, on-site employees and resident employees	$
Class Code 8810 - Total payroll dollar for strictly Clerical Employees	$
Other Class Codes (Description)	$

GENERAL INFORMATION

Hours of Operation:

Monday - Friday
to

Saturday
to

Sunday
to

Total Number of Employees:

Full Time

Part Time

Do you have an employee(s) residing on the premises?

Yes No

Age of Resident Employee	yrs
Length of time as Resident Employee	yrs mos
Do Spouse and/or other family live on premises?	Yes No
Job Description of Resident Employee
Are written procedures in place that address after hours vandalism, attempted breakins and other breaches of security?	Yes No
Do those procedures instruct resident employee(s) to advise local law enforcement of such occurrences?	Yes No
Do those procedures prohibit employee(s) from investigating the cause of such breaches?	Yes No

Any past, present or future with the storing, treating discharging, applying, disposing of or transporting of hazardous waste?	Yes No
Group Medical Provided?	Yes No

Percentage of employees participating

Is it formal or Informal?

Formal Informal

Do you have a written safety program in operation?	Yes No
Have you had any workers compensation losses in the past 5 yrs?	Yes No
Do you have hard copy loss runs?	Yes No

Submitting this questionnaire does not bind workers' compensation insurance coverage. You will be contacted within 2 business days from the date of your submission.

Submit Application

Millennium Risk Management And Insurance Services™ – License No. OC 13480
Industry Notice
Copyright ©2008 Millennium Corporate Solutions.
MILLENNIUM CORPORATE SOLUTIONS, MILLENNIUM RISK SERVICES, INC., MILLENNIUM RISK MANAGEMENT AND INSURANCE SERVICES, and the M LOGO are the trademark(s) or registered trademark(s) of Millennium Corporate Solutions.
Legal Notice
site by xylosystems

home | locations | contact | employment | site map

Workers' Comp Program

Self Storage Application