August 22, 2017

WorkersComp

General Information
Contact Name *
Email *

Business Name
Address
City
State
Zip
County
Business Phone
Fax
Current Insurance Company
(not agency)
Company Name
Policy Expiration Date
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Insurance Information
Other
Annual Gross Sales: (before taxes)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested $300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.