Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405

Name (as it should appear on policy)

Name of Company

Street Address




Zip Code

Email Address

Phone Number

Drivers License Number and State Issued In

Current Workers Comp Insurance Carrier, if none, type NONE

How many years have you been with this carrier

Current Workers Comp policy #

Current Workers Comp policy expiration date

Current Workers Comp Insurance Premium:

Current MOD Factor

Current Workers Comp Insurance Limit & Deductible and States Admitted In

Have you filed any claim with your current Workers Comp carrier?

If you have filed any claims with your current WC carrier, please advise how many and amounts paid, per policy year.

# of full-time employees

# of part-time employees

Owner’s Name

Tax ID# or SS# if individual (required)br/>

Years in business

Annual Gross sales

Square Footage

Estimated Payroll per month

Type of Business

Please describe your business:

Owners / Partners / Officers : please provide full name, title, date of birth, % ownership, duties and annual remuneration for each.

Do you want to INCLUDE or EXCLUDE workers comp coverage for owners/principles/partners?

Payroll Information: Please provide class code, job duties, annual payroll for each.

Does the company own, operate or lease aircraft/watercraft?

Any past, present or discontinued operations involving the storing, treating, discharging, applying, disposing, or transporting of hazardous material?

Any work performed underground or above 15 feet?

Any work performed on barges, vessels, docks, bridge over water?

Is applicant involved in any other type of business?

Are sub-contractors used? If yes, please give % of work subcontracted in additional comments at the end of this form

Any work sublet without certificates of insurance?

Is a written safety program in operation?

Any group transportation provided?

Any employees under the age of 16 or over the age of 60?

Any seasonal employees?

Is there any volunteer or donated labor?

Any employees with physical handicaps?

Do employees travel out of state?

Are athletic teams sponsored?

Are physicals required after offers of employment are made?

Any prior coverage declined/cancelled or non-renewed in the last 3 years?

Is there a labor interchange with any other business or subsidiary?

Do you lease employees to or from other employers?

Do any employees predominately work at home?

Any tax liens or bankruptcy within the last 5 years?

Any undisputed and unpaid workers comp premium due from or any commonly managed or owned enterprises? If yes, please explain below.

How did you hear about us?

Additional Comments

Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@allprocoverage.com. Do not “Refresh” the page because all data entered onto the form will be lost.

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Zolofra Insurance Agency
P.O. Box 868
Oakhurst, NJ 07755
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
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