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Property Liability and workers comp insurance - Protect Your Business

 

 

WORKERS COMPENSATION SURVEY

Complete the following information if you would like to obtain a Workers Compensation Insurance 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.)

If you would like to print and fax the Workers Compensation Survey to us, please open up the Adobe Acrobat version. (Fields marked with * are mandatory)

Company Name:
* Phone:
(please include area code)
* Email:
* Contact name for inspections or questions:
* Address:
Address:
City:
State:   Zip:
Type of business:
Type of work performed, services provided, and product manufactured. Please provide a detailed description:
Any safety program in effect? If yes, describe:
Do employees drive their own vehicles on Employer's business?
Number of locations?
What are your hours of operation?
Number of years experience in this field?
Projected Annual Revenue
Has the insured ever been in bankruptcy?
When would you like your new policy to take effect?

Class Code
Employee Job Description		 # of Employees

Full Time or Part Time		 Estimated Annual Payroll
$
$
$
$
If Corporation, please list

Name		 Title (included or excluded) Payroll

Your current carrier:
(so we don't quote same rates)
Experience Mods?
Tax ID#:
Number of losses in last 3 years:
Number of years in Business:

Group Benefit Plans please select below

Employer pays or more for ALL Employees
Benefits provided only to management and supervisors
No employer provided Health Care
401K/IRA/SEP

Do you offer paid sick leave? Yes    No

Do you have general liability insurance? Yes    No

 

 
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