Workers Compensation

Workman's Compensation Insurance Quote
*Business Name:
*Contact Name:
*State:     *Zip:
*Business Phone:
*Contact Email Address:
Current Insurance Information
Insurance Company Name:
Any losses in last 3 years?
# of claims: Claim amt paid $
Premium Amount $ Expiration Date:
MOD Factor: Policy Number:
Description of current coverage:
Prior Carrier Info
Previous Insurance Company Name:
Premium amount $ How long w/previous:
MOD Factor: Policy Number:
Description of prior coverage:
About Your Business
# of full-time: # of part-time:
Owner's Name: # of locations:
License Type: Years in business:
Annual Gross Sales: Square Footage:
Please describe your business here:
Owners / Partner / Officers
Name Date of Birth Title Ownership %
Payroll Information
Class Codes: Employee Duties Annual Payroll $ Hourly Wage $
General Information
Do you offer safety programs?    
Do offer health benefits to majority of employees?    
Do you employ any minors(under 18)?    
Is operation all/part of existing business that was purchased/acquired?    
Do you use subcontractors?    
Use any equipment that bends/shapes/forms?    
Are athletic teams sponsored?    
Been a lapse in coverage during past 12 months?    
Any work above 15 feet?    
Had a bankruptcy in past 7 years?    
Are you a member of any trade organizations?    
Additional Comments
Please give any additional comments or questions:

No coverage of any kind is bound or implied by
submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
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