Workers' Compensation Insurance Quote
We would like to provide you with a free, no-obligation Workers' Compensation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Business Name:
Contact Name:
Address:
City:   State:   Zip:
Business Phone:   Cell Phone:   Fax:
Contact Email Address:
Business Web Address:
Business Type:     Years in Business:
Federal ID/EIN #:


Current Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
Years with Company:
NCCI Number:
NCCI 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  


About Your Business
# of full-time
employees
# of part-time
employees
How long
in business
How many
locations
Estimated Annual
Payroll
years
$
Please give a brief description of your business (below):


Additional Business Information
Do you have any losses in the past 3 years?: Yes No
Do you have Independent Contractors?: Yes No
If yes, how many?:
Do paychecks reflect the above name?: Yes No
If no, please provide details:
Federal Tax TD:
Type: Corporation Partnership
Individual    Other
Average hourly wage for non-physician employees: $ / hour
List all Officers/Partners
Name: Title: % Ownership: Excluded/Included:
What is the business specialty?
Off premise operations: Yes No


Employee Information
Employee#
Classification code
Estimate Yearly Payroll
1
2
3
4
5
Please list additional employees in the "Additional Comments" section below

 
Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years.
This information is kept strictly confidential

Claim #1
  Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2
  Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $


Additional Comments
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.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   


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