Workers Compensation Insurance Quote Form
Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed, or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.
I have read and agree with the above disclaimer.
(Box must be checked before request can be sent)
First & Last Name:
Street Address:
City, State & Zip:
E-Mail Address:
Telephone:
Fax:
Current Insurance Information
Insurance Company Name:
Any losses in last 3 years?:
# of claims:
Claim amt. pd $:
Premium Amount:
Policy Exp. Date:
MOD Factor:
Policy #:
Describe the type of Coverage you currently have:
Prior Carrier Info
Insurance Company Name:
# of claims:
Claim amt. pd $:
Premium Amount:
How many years with:
MOD Factor:
Policy #:
About Your Business
# of Full-time:
# of Part-time:
Owner's Name:
Fed Tax ID:
License Type:
Yrs in Business:
License #:
# of locations:
Annual Gross Sales:
Square Footage:
Est payroll / mo.:
Type of Business:
Please Select..
Wholesaler
Retailer
Manufacturer
Contractor
Service
Other
Please describe your business here:
Owners / Partner / Officers
Name
Date of Birth
Title
Ownership %
Payroll Information
Class Codes
Employee Duties
Annual Payroll $
Hourly Wage $
General Information
Do you offer safety programs?
Please select..
Yes
No
Do offer health benefits to majority of employees?
Please select..
Yes
No
Do employ any minors (under 18)?
Please select..
Yes
No
Is operation all/part of existing business that was purchased/acq.?
Please select..
Yes
No
Do you use subcontractors?
Please select..
Yes
No
Use any equipment that bends/shapes/forms?
Please select..
Yes
No
Are athletic teams sponsored?
Please select..
Yes
No
Been a lapse in coverage during past 12 months?
Please select..
Yes
No
Any work above 15 feet?
Please select..
Yes
No
Had a bankruptcy in past 7 years?
Please select..
Yes
No
Are a member of any trade organizations?
Please select..
Yes
No
Additional Information
:
Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.
