WORKERS COMPENSATION INSURANCE QUOTE

Personal Information
First Name:*  
Last Name:*  
Date of Birth:*
Email:  
Day Phone:*
Evening Phone:  
Fax:  
Best time to reach:
Street Address:  
Street2:  
City:  
State:  
Zip code:  
 
Current Insurance Information
 
Insurance Company Name:
Any Claims In Last 3 Yrs: 
Howlong with current Insurance:
Claim Amount Paid: 
Policy Exp. Date:
Premium Amt:
MOD Factor:
Policy Number:
 
Prior Insurance Information
 
Insurance Company Name:
Howlong With Prior Insurance:
Number Of Claims: 
Claim Amount Paid: 
Premium Amt:
MOD Factor:
Policy Number:
 
Enter Business Information
 
Owner's Name:
Federal Tax ID:
License Type:
License Number:
Number Of Years In Business:
Number Of Locations:
Number of FullTime Employees:
Est. Payroll Per Month:
Number of PartTime Employees:
Annual Gross Income:
Building Square Footage:
Type Of Business:
Enter Brief Description About Your Business:
OWNERS / PARTNERS
 
  Name:
Date Of Birth:
  Position:
% Of Ownwership:
Owner 1
Owner 2
Owner 3
Owner 4
PAYROLL
Class Codes:
Employee Duties:
Hourly Wages:
Annual Payroll:
ADDITIONAL INFORMATION
Do offer health benefits to majority of employees? Yes No
Do you offer safety programs? Yes No
Do you use subcontractors? Yes No
Do employ any minors (under 18)? Yes No
Are athletic teams sponsored? Yes No
Any work above 15 feet? Yes No
Use any equipment that bends/shapes/forms? Yes No
Are a member of any trade organizations? Yes No
Had a bankruptcy in past 7 years? Yes No
Been a lapse in coverage during past 12 months? Yes No
Questions/Comments
Please enter your question/request information: