Workers Compensation Quote Sheet
Information entered into this can be saved and returned to later when all information necessary to prepare a quote is available. Your information will only be used for the purposes of providing a proposal for workers' compensation coverage and will not be shared or sold to outside affiliates.
Business Name
*
Insured Name
*
Business Phone
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Point of Contact within the Company for Question Related to this Submission
*
Point of Contact's Telephone Number
*
Please enter a valid phone number.
Business Email
*
Website URL
*
Federal EIN Tax ID Number
*
Business Entity Type (Sole Proprietorship, Corporation, etc.)
*
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Is this a newly formed business or hiring employees for the first time? .
*
YES
NO
Does the business operate from any other locations or have any other offices?
*
YES
NO
What year was the business established?
*
What year was the current ownership established?
*
What year were employees first hired with current ownership?
*
What is your estimated annual revenue?
*
What is your estimated annual payroll?
*
Does your company own or operate any commercial vehicles?
*
YES
NO
# of Full Time Employees
*
# of Part Time Employees
*
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Do you have Loss Runs that are no more than 120 days old?.
*
YES
NO
Have there been any loss occurrences in the past 3 years? .
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YES
NO
Owners/Executive Officers - Provide Names, Official Titles, Percentage of Business Ownership, and Estimated Annual Compensation.
*
Do the named Owners/Executive Officers want to be included for coverage on the Workers Compensation Policy?
YES
NO
Please Provide a General Description of Business Operations (and Products):
*
Does the company subcontract any work?
*
YES
NO
Do you own, rent, or lease your office space?
*
Own
Rent
Lease
Has the company ever had its Workers Compensation coverage canceled (for reasons other than non-payment) or non-renewed within the last 3 years, or had a lapse in coverage within the last 3 years?
*
YES
NO
Does the company hire contract employees or pay employees with a 1099?
*
YES
NO
Are all 1099 employees or subcontractors required to provide Certificates of Insurance?
*
YES
NO
NA
Are you interested in any of the following?
Business Owners Coverage
General Liability
Commercial Auto
Buy-and-Sell Life Insurance
Employer Sponsored 401K
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