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Workers Comp Quote

Workers Compensation Insurance Quote Form

Contact 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 long with current:

MOD Factor:

Policy #:

About Your Business

# of Full-time:

# of Part-time:

Owner's Name:

License Type:

Yrs in Business:

Annual Gross Sales:

# of locations:

Est payroll / mo.:

Square Footage:

Please describe your business here:

Type of Business:

Owners / Partner / Officers

Name

Date of Birth

Title

Ownership %

Name

Date of Birth

Title

Ownership %

Name

Date of Birth

Title

Ownership %

Payroll Information

Class Codes

Employee Duties

Annual Payroll $

Hourly Wage $

Class Codes

Employee Duties

Annual Payroll $

Hourly Wage $

Class Codes

Employee Duties

Annual Payroll $

Hourly Wage $

Class Codes

Employee Duties

Annual Payroll $

Hourly Wage $

General Information

Do you offer safety programs?

Do offer health benefits to majority of employees?

Do employ any minors (under 18)?

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

Do you use subcontractors?

Use any equipment that bends/shapes/forms?

Are athletic teams sponsored?

Been a lapse in coverage during past 12 months?

Any work above 15 feet?

Had a bankruptcy in past 7 years?

Are a member of any trade organizations?

Additional Comments

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

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.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.