Workers Comp Quote

Workers Compensation Insurance Quote Form

Contact Information

Current Insurance Information

Insurance Company Name:
Any losses in last 3 years?:
# of claims:		Claim amt. pd $:
Premium Amount:		Policy Exp. Date:
MOD Factor:		Policy #:
Describe the type of Coverage you currently have:

Prior Carrier Info

About Your Business

# of Full-time:		# of Part-time:
Owner's Name:		Fed Tax ID:
License Type:		Yrs in Business:
License #:		# of locations:
Annual Gross Sales:		Square Footage:
Est payroll / mo.:		Type of Business:
Please describe your business here:

Owners / Partner / Officers

Payroll Information

General Information

Do you offer safety programs?
Do offer health benefits to majority of employees?
Do employ any minors (under 18)?
Is operation all/part of existing business that was purchased/acquired?
Do you use subcontractors?
Use any equipment that bends/shapes/forms?
Are athletic teams sponsored?
Been a lapse in coverage during past 12 months?
Any work above 15 feet?
Had a bankruptcy in past 7 years?
Are a member of any trade organizations?

Additional Comments

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

YES! I Agree