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WORKERS COMPENSATION INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a Workers Compensation Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your business name?
Business Name
What is your address?
Street
City
State
Zip
What is your telephone number?
Home
Business
What is your fax number?
Fax
What is your email address?
Email
Underwriting Information
What is the nature of your business?
Nature of Business
Is the business a corporation, partnership or sole proprietorship?
Corporation
Partnership
Sole Proprietorship
How many owners?
Number of Owners
How many employees?
Number of Employees
What is the payroll amount of the owners?
Payroll of Owners
What is the payroll amount of the employees?
Payroll of Employees
What is the total annual gross?
Total Annual Gross Receipts
What is the business license number?
Business License Number
What is the license type?
License Type
Years of experience in this business?
Years of Experience
How many years have you operated under your current business name?
Years Operated Under Current Name
Have you used any other business names during the past 5 years?
Other Business Names
Yes No
Is this business open 24 hours a day
Open 24 Hours
Yes No
Any deep frying (food)?
Deep Frying
Yes No
Is there any manufacturing, mixing, re-labeling or repackaging of products?
Manufacturing
Yes No
Is there filling of propane tanks?
Propane Tank Filling
Yes No
Please describe the nature of your business and ANY unusual exposures.
Unusual Exposures
Payroll Detail Information
  Class/Code Payroll Rate Annual Payroll
Employee Group 1
Employee Group 2
Employee Group3
Employee Group 4
Employee Group 5
Claims Information
Where there any losses or claims in the last 5 years?
Losses - Claims
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the liability limit requested?
Liability Limit
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
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