Name (as it should appear on policy)
Name of Company
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
Tax ID# or SS# if individual (required)br/>
Years in business
Annual Gross sales
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.
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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.
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Name Of Your Company or type of business if seeking commercial insurance (required)
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Zip Code (required)