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


    *Phone Number

    Alternate Number

    *Email Address

    Underwriting Information

    What is the nature of your business?

    Is the business a corporation, partnership, or sole proprietorship?

    CorporationPartnershipSole 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?


    Any deep frying (food)?


    Is there any manufacturing, mixing, re-labeling or repackaging of products?


    Is there filling of propane tanks?


    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?



    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


    Or Specify Other:

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