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Workers' Compensation
"20 Question Quote" Form

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

1. Insured Name:
  Phone Number:
  E-mail:
2. Business Name:
  Business Website:
3. Address:
  City:
  State:     Zip:
4. Tax ID Number:
5. Effective Dates: to
6. Desired/Renewal Premium:   (Don’t Know )
7. Current Insurer:
8. Legal Entity (LLC?  Corp?  Partnership?):
9. Nature of Business/Description of Operations:
10. Liability Limits Desired:
100/500/100   500/500/500   1M/1M/1M
11. Class & Payroll:
  a. Class Code        Description:
     Employees:    Payroll: $
  b. Class Code        Description:
     Employees:    Payroll: $
  c. Class Code        Description:
     Employees:    Payroll: $
12. Have you been in operation for at least 3 years? Yes No
13. Do you have prior workers’ compensation coverage? Yes No
14. Is your loss ratio (average annual losses/quoted premium) Yes No
less than 40%?
15. Hours of Operation:
  Open after 6:00 PM: 
Open after 9:00 PM:
Open after Midnight:
Open after 2:00 AM: 		Yes No
Yes No
Yes No
Yes No
16. Do employees ever work at heights exceeding 15 feet? Yes No
17. Are employees involved in trucking or
transportation operations? Yes No
18. Do employees handle hazardous materials? Yes No
19. Number of full-time employees?
  Number of part-time employees?
20. Maximum number of employees working at one time at a location?
   

REQUIRED. By checking this box, I understand that the Information provided above (and, possibly, additional information) to be used to get non-binding pricing indication.



 
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