Workers Compensation Quote Form

General Information

Name of Business:

Contact Name:

Street Address:

City:

  State:    ZIP:

County:

  Email:

Business Phone:

( )         

Fax:

( )

Current Insurance Company (not agency)

Company Name:

Policy Exp. Date: 

Current Premium

About Your Business:

# of full-time employees

# of part-time employees

How long in business

How many locations

Annual Sales

yrs.

$

Please give a brief description of your business:

Federal Information:

Federal I.D. Number Experience Modification

Rating Information:

Classification Description
(By Employee Group)

Gross Annual Payroll
(By Group)

Names of Owners / Corporate Officers:

Name:

Social Security Number:

YES or NO

Included under comp.

Excluded under comp.

Name:

Social Security Number:

Included under comp.

Excluded under comp.

Name:

Social Security Number:

Included under comp.

Excluded under comp.

Name:

Social Security Number:

Included under comp.

Excluded under comp.

Name:

Social Security Number:

Included under comp.

Excluded under comp.

Additional Comments:

Describe any claims you have had in the past 3 years.

 

Thank you for your time in submitting this Workers Compensation Insurance Quote Form.
One of our representatives will respond to your submission as soon as possible!