Workers Compensation Quote Form

General Information

Type of Business

Employee Information

Officers/Partners/Owners Information

Prior Carrier Info

Services

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Quote Requests

Effective Date:*

Business Name:*

Business Phone:

Address:*

Zip/Postal Code:*

City:*

State: *

Contact Name: *

Federal Employer's ID:

Principal's SS#:

Type of Business:*

Year this business started under the current ownership:*

Years of total overall experience the owner has in this business type:*

Losses past 3 years:*

Description of losses or if possible, please include currently valued loss runs:

# Full Time Emp.:*

# Locations:*

Experience Mod:

# Part Time Emp.:*

Est. Total Annual Payroll:

Do you require increase limity beyond 100/500/100? If so, please state limits needed:

		Principal Name		Title		Excluded?	Annual Payroll (Optional)
1	*		*		*
2
3

Job Description

Class Code (Optional)

Annual Payroll Estimate

Prior Carrier Company:*

Prior Carrier Premium:*

Prior Carrier Term:*

Additional Information/Remarks/Additional Location Address: