Workers Compensation Quote Request

Contact Information
Name:
Address:
Business Name
City:   State:  
Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:
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
Were 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 Premium
What is the liability limit requested?
Liability Limit
Questions,Comments or Additional Coverage
What is 5+12?
(Are you human?)


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