Posts Tagged ‘workers compensation’

Workers Compensation

Thursday, May 20th, 2010

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.

Name
Business Name
Street Address
City and Zip
Phone Number
Alternate Telephone
Fax Number
Email Address
Underwriting Information
What is the nature of your business?
What is your business entity
Number of owners or officers
Number of Employees
Payroll of Owners/Officers
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 the nature of your business and 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: