Workers Compensation Insurance Quote

Quote Request

Complete the following information if you would like to obtain a 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

*First Name
*Last Name
Business Name
Business Address
City/St/Zip
*Phone Number
Alternate Number
*Email Address

Underwriting Information

What is the nature of your business?
Is the business a corporation, partnership, or sole proprietorship?  Corporation Partnership Sole Proprietorship
Number of Owners
Number of Employees
Payroll of Owners
Payroll of Employees
Total annual gross receipts
Business License Number
License Type
Years of experience
Years operated under current name
Other business names
Is this business open 24 hours a day?  Yes No
Any deep frying (food)?  Yes No
Is there any manufacturing, mixing, re-labeling or repackaging of products?  Yes No
Is there filling of propane tanks?  Yes No
Please describe ANY unusual exposures:

Payroll Detail Information

Employee Group 1
Class / Code
Payroll Rate
Annual Payroll
Employee Group 2
Class / Code
Payroll Rate
Annual Payroll
Employee Group 3
Class / Code
Payroll Rate
Annual Payroll
Employee Group 4
Class / Code
Payroll Rate
Annual Payroll
Employee Group 5
Class / Code
Payroll Rate
Annual Payroll

Claims Information

Were there any losses or claims in the last 5 years?  Yes No
  If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

Current Insurance Company
How much are you paying now?
What is the liability limit requested?
Questions or Comments
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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