For Your Business

Workers Compensation Insurance Quote

Workers Compensation insurance is a state mandated insurance coverage to protect employees from work related injuries or death. If you have employees, you are required to carry this coverage.

General Information

Company

Contact Person

Email Address

Address

City

State

Zip Code

Home Phone

Work Phone

Fax Number

Address of Properties (if different from above)

2nd Address (street,city,zip)

3rd Address (street,city,zip)

4th Address (street,city,zip)

Company Information

Type of Company --Select One-- Individual Partnership Corporation S-Corporation Other

If Individual

Owner's Name

Social Security #

Spouses Name

Social Security #

Years in Business

License Number

NCCI Number

Other Rating BureauID Number

Total Gross Receipts

Employees Payroll

Nature of Business operations

Rating Information

Location

Class Code

Categories, Duties

# of Employees

Estimated Annual Remuneration

Individuals to be Included or Excluded

Person

Name

Date of Birth

Title Relationship

Ownership %

Duties

Inc/Exc

Renumeration

1

2

3

4

Prior Carrier Information / Loss History

Year

Carrier

Policy #

Annual Premium

MOD

# Claims

Amount Paid

Reserve

General Information (explain all "yes" answers in remarks)

1. Does the applicant own, operate or lease Aircraft/Watercraft?

Yes No

2. Do/have past, present or discontinued operations involve(d) storing, treating, discarging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)

Yes No

3. Any work performed underground or 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

6. Are sub-contractors used?

Yes No

7. Any work sublet without certificate of Insurance?

Yes No

8. Is a formal 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 part time or seasonal employees?

Yes No

12. Is there any volunteer or donated labor?

Yes No

13. Any employees with physical handicaps?

Yes No

14. Do employees travel out of state?

Yes No

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/cancelled/non-renewed (last 3 years)?

Yes No

19. Are employee health plans provided?

Yes No

20. Is there a labor interchange with any other business/subsidiary?

Yes No

21. Do you lease employees to or from other employers?

Yes No

22. Do any employees predominantly work at home?

Yes No

Contact Information (Name & Phone Number)

Inspection

Accounting Records

Claims Info

Remarks and Comments

Reporting Method

How would you like to receive your free Workers Comp quote? --Select One-- U.S.Postal E-mail Telephone Fax

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