Workers Compensation Insurance Quote Request

Workers Compensation Quote Request

Your Information

Last Name*

First Name*

Birth Date*

Business Name*

What is your position?*

Email Address*

Street Address*

City*

State*

Zip Code*

Phone Number*

Alternate Phone

Fax Number

Please let us know the best time to call and discuss your quote. Morning
Afternoon
Evening
Anytime

Underwriting Information

What is the nature of your business? (250 chars left)

Is the business a corporation, partnership, or sole proprietorship? Corporation
Partnership
Sole proprietorship

Number of owners

Number of Employees

Payroll of Owners

Payroll of Employees

Total annual gross receipts

Business License Number

License Type

Years of experience

Years operated under current name

Other business names Yes
No

Is this business open 24 hours a day? Yes
No

Any deep frying (food)? Yes
No

Is there any manufacturing, mixing, re-labeling or repackaging of products? Yes
No

Is there filling of propane tanks? Yes
No

Please describe the nature of your business and ANY unusual exposures: (1000 chars left)

Payroll Detail Information

Employee Group 1

Class / Code

Payroll Rate

Annual Payroll

Employee Group 2

Class / Code

Payroll Rate

Annual Payroll

Employee Group 3

Class / Code

Payroll Rate

Annual Payroll

Employee Group 4

Class / Code

Payroll Rate

Annual Payroll

Employee Group 5

Class / Code

Payroll Rate

Annual Payroll

Claims Information

Were there any losses or claims in the last 5 years? Yes No

If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

Current Insurance Company

How much are you paying now?

What is the liability limit requested?

Best Time To Contact You

Please let us know the best time to call and discuss your quote. Morning
Afternoon
Evening
Anytime

Any Questions or Comments? (1000 chars left)

Please type what you see

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