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Workers Compensation Quote

1. Date: What date does your Current policy expire? ( mm/dd/yyyy)
2. Name:     Email:
3. Mailing Address: City: County:
4. Telephone:    Home #: Work #:   Mobile #:
5. Type of Contractor:
6. Exact Name of Business:
7. Name of Business Owners: Title:
Title:
8. Nature of business / Description of operations:
9. How many employees in your operation: 1 2 3 4 5 More than
10. What is your total annual payroll?  $
11. What is your total annual gross receipts?  $
12. How much employer's liability is needed?: $500,000 $1,000,000      Are you : Individual Partnership Corporation LLC
13. Number of Full-Time workers:     |        Number of Part-Time workers:
14. How many years have you been engaged in business?
15. Please describe any losses in past 3 years?
16. Do you need any liability insurance?   Yes No
17. Has your insurance ever been cancelled?   Yes No   If YES, Please explain:
18. Do you own any other property?   Yes No
19.Accounting Records: Call: At:
20. Are Certificates of Insurance required from Sub-contractors?   Yes No
21. Is formal safety in operation?   Yes No
22. Are any employees over 65 or under 18?   Yes No
23. Any volunteered or donated labor?   Yes No
24. Any underwater or offshore work?   Yes No
25. What company insures you now: Current premium: $
26. Why do you want to switch:     Pricing: Switch Agent: Being Cancelled: Cancelled:
Finish
27. Referred by: Please Select Friend Net Quote Internet Yellow Pages Newspaper    Other:
Notes:
Reproduction of this Questionnaire is restricted unless permission is given.

 
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