Workers Compensation Quote Form
Company Name*:
Address*:
City*:
State*:
Zip*:
First Name*:
Last Name*:
Title:
Email Address*:
Telephone*:
Fax:

About Your Business
# of Full-time Employees:
# of Part-time Employees:
Owner's Name:
Fed Tax ID:
License Type:
License #:
Number of years in business:
Number of locations:
Annual Gross Sales:
Square Footage:
Estimated monthly payroll:
Type of Business:
Please describe your business here:

Owners/Partner/Officers
Owner #1
Name:
Date of Birth:
Title:
Ownership %:
Owner #2
Name:
Date of Birth:
Title:
Ownership %:
Owner #3
Name:
Date of Birth:
Title:
Ownership %:
Owner #4
Name:
Date of Birth:
Title:
Ownership %:

Payroll Information
Payroll Class #1
Class Codes:
Employee Duties:
Annual Payroll $:
Hourly Wage $:
Payroll Class #2
Class Codes:
Employee Duties:
Annual Payroll $:
Hourly Wage $:
Payroll Class #3
Class Codes:
Employee Duties:
Annual Payroll $:
Hourly Wage $:
Payroll Class #4
Class Codes:
Employee Duties:
Annual Payroll $:
Hourly Wage $:

General Information
Do you offer safety programs?:
Do offer health benefits to a majority of employees?:
Do employ any minors (under 18)?:
Was any part of the business purchased or acquired?:
Do you use subcontractors?:
Is equipment that bends/shapes/forms used?:
Are athletic teams sponsored?:
Has there been a lapse in coverage during the past 12 months?:
Is work performed above 15 feet ?:
Had a bankruptcy in past 7 years?:

Current Insurance Information
Current Insurance Company Name:
Current Agent Name:
Policy Number:
Policy Expiration Date:
Premium Amount:
MOD Factor:
Describe the type of Coverage you currently have:
Any losses in last 3 years?:
# of claims:
Claim amount paid $:

Prior Carrier Information
Prior Carrier Name:
Prior Policy #:
How many years with:
Premium Amount:
# of claims:
Claim amount paid $:
MOD Factor:

Additional Information

Is the business a member of the local Chamber of Commerce?:
Please indicate the local chamber name:

How did you hear about us?:

Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for:
Note: By submitting this form you understand that a representative will contact you regarding an insurance quote. Please know that coverage is not bound. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. The provided information will be used soley for insurance quoting purposes and will not distribute to other parties.

Additional information