December 15, 2017

Workers Compensation Quote

Business Information
Contact Name *
Contact Email *
How did you hear about us? *

Business Name
Address
City
State
Zip
Business Phone
Cell Phone
Fax
Website
Preferred Method of Contact? Business Phone  Cell Phone  Email  Fax
General Information
FEIN #
How long in Business? (yrs)
Business Type
# of Full-Time Employees
# of Part-Time Employees
How Many Locations?
Please give a brief description of your business operations
Current Insurance Company
Insurance Company Name
Policy Expiration Date
Policy Number
Coverage Information
Limits Requested $500,000  $1,000,000
Experience Modifier
Describe any claims you've had in the past 5 years
Additional Comments
Class Codes
  Class Code # Description Payroll # Employees
1.
2.
3.
4.
5.
Owners
  Name Title Percent Ownership Include / Exclude Class Code
1.
2.
3.
4.
Questions
1. Does applicant own, operate or lease aircraft / watercraft? Yes  No
If "yes" above - please describe.
2. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? Yes  No
3. Any work performed above 15 feet? Yes  No
4. Any work performed on barges, vessels, docks, bridge over water? Yes  No
5. Is applicant engaged in any other type of business? Yes  No
If "yes" above - please describe.
6. Are sub-contractors used? Yes  No
If "yes" above - give % of work subcontracted.
7. Any work sublet without certificates of insurance? (If "yes" - payroll for this work must be included in the class codes above) Yes  No
8. Is a written safety program in operation? Yes  No
9. Any group transportation provided? Yes  No
10. Any employees under 16 or over 60 years of age? Yes  No
11. Any seasonal employees? Yes  No
12. Is there any volunteer or donated labor? Yes  No
If "yes" above - please describe.
13. Any employees with physical handicaps? Yes  No
14. Do employees travel out of state? Yes  No
If "yes" above - what state(s) and frequency?
15. Are athletic teams sponsored? Yes  No
16. Are physicals required after offers of employment are made? Yes  No
17. Any other insurance with this insurer? Yes  No
18. Any prior coverage declined / canceled / non-renewed in the last 3 years? Yes  No
19. Are employee health plans provided? Yes  No
20. Do employees perform work for other businesses or subsidiaries? Yes  No
21. Do you lease employees to or from other employers? Yes  No
22. Do ant employees predominately work from home? Yes  No
23. Any tax liens or bankruptcy in the last 5 years? Yes  No
If "yes" above - please describe.
24. Any undisputed and unpaid workers compensation premium due from you or ant commonly owned enterprise? Yes  No
If "yes" above - please explain.

Comments
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.