Work Comp Insurance Quote

Work Comp Quote

Name
First Last
Business Name
Mailing Address
Street Address Business Address if Different from Above City State / Province / Region ZIP / Postal Code
Phone
Email
Proposed Work Comp Start Date
Month /Year Business Started (XX / XXXX)
Nature of Business
Number of Employees (Full Time)
Number of Part Time Employees
Estimated Annual Gross Revenue
Estimated Annual Employee Payroll
Do you have a WCIRB number? If Yes, What is your WCRIB number?
Do you have an experience mod number? If yes, What is exp. mod number?
Federal Employee Identification Number (FEIN) or SSI number
Legal Entity
If Other - Describe
Owners / Officers Name (Owner/ Officer #1)
First Last
Title Owner /Officer #1
Percentage of Ownership (Owner/ Officer #1)
Included / Excluded (Owner/ Officer #1)
Add Officer # 2
Owners / Officers #2 Name
First Last
Title Owner /Officer #2
Percentage of Ownership (Owner/ Officer #2)
Owner / Officer # 2 Included / Excluded
Add Officer # 3
Owners / Officers # 3 Name
First Last
Title Owner /Officer # 3
Percentage of Ownership (Owner/ Officer #3)
Owner / Officer # 3 Included / Excluded
Add Officer # 4
Owners / Officers # 4 Name
First Last
Title Owner /Officer # 4
Percentage of Ownership (Owner/ Officer #4)
Owner / Officer # 4 Included / Excluded
Inspection Contact -Name
First Last
Inspection Contact Phone
Prior Work Comp (in Last 4 Years)
Current Annual Premium
Year (last Year) Coverage
Work Comp Insurance Company Name (1)
Year (Two Years Ago) Coverage
Work Comp Insurance Company Name (2)
Year (Three Years Ago) Coverage
Work Comp Insurance Company Name (3)
Year (Four Years Ago) Coverage
Work Comp Insurance Company Name (4)
Year (Five Years Ago) Coverage
Work Comp Insurance Company Name (5)
Any Losses in the Past 5 Years
Number of Losses in past 5 years
Provide Date, Description of Loss 1, Amount of Loss
Provide Date, Description of Loss 2, Amount of Loss
Provide Date, Description of Loss 3, Amount of Loss
Provide Date, Description of Loss 4, Amount of Loss
Please provide / upload Loss Runs for Past 5 Years
Max. file size: 20 MB.

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