Workers' Comp Insurance Quote General Information Current Health Insurance Information About Your Business Coverage Limits Employee Information Owners, Partners, and Officers Information Claims History (Please describe any claims during the past three (3) years Business Information Additional Comments Legal Business Name Contact Name Address City State Zip Code Business Status IndividualCorporationPartnershipJoint Venture Business Tax ID Number Business Phone Best Time To Call AM PM Email Address Proceed Are You Current Insured? YesNo Current Insurance Carrier (Not Agency) Policy Expiration Date Premium Amount NCCI Number Experience Modification Number What type of coverages do you currently have Bond Commercial Auto Commercial Liability Commercial Property Commercial Umbrella Directors & Officers Liability Disability Group Health Group Life Professional Liability Other Back Proceed # of Full Time Employees # of Part Time Employees Give a complete description of any type of hazardous/dangerous duties performed by your employees Back Proceed Coverage Limits Desired $ Back Proceed Employee 1 Classification Code Employee 1 Yearly Payroll Estimate Employee 2 Classification Code Employee 2 Yearly Payroll Estimate Employee 3 Classification Code Employee 3 Yearly Payroll Estimate Employee 4 Classification Code Employee 4 Yearly Payroll Estimate Employee 5 Classification Code Employee 5 Yearly Payroll Estimate Back Proceed #1 Position OwnerPartnerOfficerOther #1 Classification Code #1 Estimate Yearly Payroll #1 Status Included Excluded #2 Position N/AOwnerPartnerOfficerOther #2 Classification Code #2 Estimate Yearly Payroll #2 Status Included Excluded #3 Position N/AOwnerPartnerOfficerOther #3 Classification Code #3 Estimate Yearly Payroll #3 Status Included Excluded #4 Position N/AOwnerPartnerOfficerOther #4 Classification Code #4 Estimate Yearly Payroll #4 Status Included Excluded #5 Position N/AOwnerPartnerOfficerOther #5 Classification Code #5 Estimate Yearly Payroll #5 Status Included Excluded Back Proceed Date of Claim #1 Amount of Claim #1 Description of Claim #1 Date of Claim #2 Amount of Claim #2 Description of Claim #2 Date of Claim #3 Amount of Claim #3 Description of Claim #3 Back Proceed Please select all that apply to your business Operate or Lease aircrafts/watercrafts Store, treat, dispose or transport hazardous waste Work Underground Work above 15ft. Work on vessels, docks or bridges over water Require out of State travel Use Subcontractors Delivery Service Pre-employment Physicals Offer Safety and Incentive programs Other Back Proceed Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here. This includes If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or email an additional listing. Back Send
