Worker’s Compensation Insurance Quote Request

For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.

Personal Information

Select Your State

Please Note: We only write insurance for these states.

Address

What is your address?

Street Address Address Line 2 City State ZIP Code

Name*

What is your name?

First Last

Telephone Number (Day)*

What is your business telepone number?

Telephone Number (Night)

What is your home telepone number?

Best Time to Call

What is the best time to call?

:

Email Address*

What is your email address?

Fax

What is your fax number?

Underwriting Information

Nature of Business

What is the nature of your business?

Is the business a corporation, partnership or sole proprietorship?

Corporation
Partnership
Sole Proprietorship

Number of Owners

How many owners?

Please enter a number greater than or equal to 0.

Number of Employees

How many Employees

Please enter a number greater than or equal to 0.

Payroll of owners

What is the payroll amount of the owners?

Payroll of employees

What is the payroll amount of the employees?

Total Annual Gross Receipts

What is the total annual gross?

Business License Number

What is the business license number?

License Type

What is the license type?

Years of Experience

Years of experience in this business?

Please enter a number greater than or equal to 0.

Years Operated Under Current Name

How many years have you operated under your current business name?

Please enter a number greater than or equal to 0.

Other Business Names

Have you used any other business names during the past 5 years?

Yes
No

Open 24 hours

Is this business open 24 hours a day?

Yes
No

Deep Frying

Any deep frying (food)?

Yes
No

Manufacturing

Is there any manufacturing, mixing, re-labeling or repackaging of products?

Yes
No

Propane Tank Filling

Is there filling of propane tanks?

Yes
No

Unusual Exposures

Please describe the nature of your business and ANY unusual exposures.

Payroll Detail Information

Employee Groups*

Class/Code	Payroll Rate	Annual Payroll

Claims Information

Were there any losses or claims in the last 5 years?

Losses - Claims

Yes
No

What is the date, amount paid and description of each loss or claim?

Coverage Information

What is the current insurance company?

Amount Current Coverage

How much are you paying now?

Liability Limit

What is the liability limit requested?

Building Limit

What is the building limit requested?

Questions, Comments or Additional Coverage

Are there any questions, comments or additional coverage required?

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PLEASE NOTE: Insurance coverage cannot be bound without a written binder from our office

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Worker’s Compensation Insurance Quote Request