Workers' Compensation Quote Request


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Please send this information with attention to:

i. Contact Information: (* = required fields)

*Business Name
*Office Phone:
*Contact Name:
Cell Phone:
*Business Address:
Fax #:
*City:
   
*State:
 *Zip:    

*Email Address:
*Confirmation of Email Address:

When is the best time to reach you? What is the best way to reach you?

ii. Prior Insurance Information:

Are you currently insured?
  If yes, then:
  Who is your current Workers' Compensation Insurance Carrier?
  Approximately how much are you paying for your Workers' Compensation Insurance Coverage?
Have you made any claims on your Workers' Compensation insurance in the past? Yes No
  If yes, then:
 

Please give a detailed description of any losses including date of loss, amount paid out by insurance company, description of loss and steps that have been taken to make sure that the loss doesn't happen again.

iii. Business Information - Tell us about your business:

What type of entity is your business?

What is your Federal Employee Identification Number, FEIN?

Name the officers of the business, their title and whether they’d like to be included in the Workers’ Compensation coverage or not.

Name
Title
Included/Excluded?

Included Excluded
Included Excluded
Included Excluded
Included Excluded

Please give a detailed description of your business operations?
The more information you give will help us best classify your business. (required field)

iv. Payroll Information:

Please give a one or two word job description for each type of employee with their estimated, annual payroll.
  For example:
    For 2 Clerical Employees, I pay $60,000 in total.
    For 5 Sales Associates, I pay $80,000 in total.
    For 6 Installation Technicians, I pay $120,000 in total.
   
# of Employees
Type of Employees
Estimated, Annual Payroll
   
   
   
   
   
   

v. Miscellaneous Information:

Do you perform any work underground or above 3 stories? Yes No
Do you use sub-contractors? Yes No
  If yes, then:
  What percent of the work is sub-contracted (1-100)?
  Are all those sub-contractors insured? Yes No -- If no, what percent of those are uninsured (1-100)?

Any prior coverage declined/cancelled/non-renewed in the last 3 years? Yes No
Any disputed or unpaid WC premium due from you? Yes No

vi. Other Coverages:

General Liability
Business Property and/or Building Coverage
Business Automobile
Other

 
 
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