CompTrust Supplemental Application


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
For current year projection
For current year projection
For 5-Year Projection
For 5-Year Projection
Is Your Company Licensed as *
(Please provide a percentage for each)
(Please provide a percentage for each category)
Require Certificate 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? *
Post hire, which of the following of 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 agency? *
Do 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? *
Does this person have other roles besides implementing safety programs? *
Is this person certified CPR/First Aid? *
Defibrillators on each site *
Is a copy of s safety plan provided to, reviewed, signed, and filled for each employee? *
How often are toolbox meetings held?
Please check any type(s) of drug testing required of employees
Does your safety plan address business driving, including smart phone & texting policy *