Worker’s Compensation Insurance Quote

The information requested on this form will allow us to request a premium indication from multiple insurance carriers on your behalf. Should you choose to accept one of these quotes, a formal application with your signature will need to be completed.

Business Name*
Business Entity*
- LLC
- Sole Proprietor
- Partnership
- Corporation
- DBA
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is the business address the same as the mailing address?
- Yes / Not applicable
- No, it is different
Business Address
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Email*
Your Name
First Last
Your Position
Federal ID Number
# Full-time Employees
# Part-time Employees
Please classify your employees according to their duties
Duties Number of Employees

i.e. how many clerical, how many warehouse, how many sales people, how many managers etc.
Total annual payroll for all employees including owners/officers
If you are incorporated, are the executive officers excluded from coverage?
Amount of payroll for owners/executive officers only
Annual gross receipts
Do you have any employment benefit plans?

i.e. health insurance or retirement
ERISA Required?
- Yes
- No
Do you have a formal written safety protocol?
- Yes
- No
What is the best way to contact you?
- Phone
- Email
What is your current Worker's Comp expiration date?
MM slash DD slash YYYY

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Duties	Number of Employees