Workers Compensation

Workman's Compensation Insurance Quote
*Business Name:	Business is Required
*Contact Name:	Name is Required
*Address:	Address is Required
*City:	City is Required
*State:	*Zip: Required
*Business Phone:	Phone is Required
Fax:
*Contact Email Address:	Email is Required Invalid Email Address

Name	Date of Birth	Title	Ownership %
Current Insurance Information
Insurance Company Name:
Any losses in last 3 years?
# of claims:		Claim amt paid $
Premium Amount $		Expiration Date:
MOD Factor:		Policy Number:
Description of current coverage:
Prior Carrier Info
Previous Insurance Company Name:
Premium amount $		How long w/previous:
MOD Factor:		Policy Number:
Description of prior coverage:
About Your Business
# of full-time:		# of part-time:
Owner's Name:		# of locations:
License Type:		Years in business:
Annual Gross Sales:		Square Footage:
Please describe your business here:
Owners / Partner / Officers



Payroll Information
Class Codes:	Employee Duties	Annual Payroll $	Hourly Wage $




General Information
Do you offer safety programs?			YES NO
Do offer health benefits to majority of employees?			YES NO
Do you employ any minors(under 18)?			YES NO
Is operation all/part of existing business that was purchased/acquired?			YES NO
Do you use subcontractors?			YES NO
Use any equipment that bends/shapes/forms?			YES NO
Are athletic teams sponsored?			YES NO
Been a lapse in coverage during past 12 months?			YES NO
Any work above 15 feet?			YES NO
Had a bankruptcy in past 7 years?			YES NO
Are you a member of any trade organizations?			YES NO
Additional Comments
Please give any additional comments or questions:
No coverage of any kind is bound or implied by submitting information via this online form Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance. We will not distribute information to other parties other than for insurance underwriting purposes. By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
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25 Years Of Trusted Insurance

Workers Compensation