Workers Compensation

Contact Information

First Name: *

Last Name: *

Email Address: *

Address: *

City: *

State: *

Zip Code: *

Day Telephone: *

Eve. Telephone:

Fax:

Current Insurance Information

Insurance Company Name: (NOT Insurance Agency/Broker) : *

Any losses in last 3 years?: *

If Yes please specify

Number of claims :

Claim amount paid $:

Premium Amount: *

Policy Exp. Date: *

MOD Factor: *

Policy Number: *

Describe the type of Coverage you currently have: *

About Your Business

Owner's Full Name: *

Number of Full Time employees: *

Number of Part Time employees: *

Fed Tax ID: *

License #: *

License Type: *

Type of Business: *

If Other, please describe your business here:

Years in Business: *

Number of locations: *

Annual Gross Sales: *

Square Footage: *

Est payroll per month: *

Owners / Partner / Officers

Name: *

DOB: *

Title: *

Ownership %: *

Name: *

DOB: *

Title: *

Ownership %: *

Name: *

DOB: *

Title: *

Ownership %: *

Payroll Information

First

Class Codes: *

Employee Duties: *

Annual Payroll $: *

Hourly Wage $: *

Second

Class Codes: *

Employee Duties: *

Annual Payroll $: *

Hourly Wage $: *

Third

Class Codes: *

Employee Duties: *

Annual Payroll $: *

Hourly Wage $: *

Fourth

Class Codes: *

Employee Duties: *

Annual Payroll $: *

Hourly Wage $: *

General Information

Do you offer safety programs?: *

Do you offer health benefits to majority of employees? : *

Do you employ any minors (under 18)? : *

Do you use subcontractors? : *

Do you use any equipment that bends/shapes/forms? : *

Do you sponsor any athletic teams? : *

Any work above 15 feet? : *

Are a member of any trade organizations? : *

Had a bankruptcy in past 7 years? : *

Is operation all/part of existing business that was purchased/acquired?: *

Has there been a lapse in coverage during the past 12 months? : *

Additional Comments

Please give any additional comments or questions :

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We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
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Workers Compensation