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Workers Compensation Insurance Quote Request
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*Required fields
are in light blue |
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Company
Information |
| Company
Name |
(legal entity) |
| Address |
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| City |
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| State |
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| Zip
Code |
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| Business
Phone |
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| Business
Fax |
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Contact
Information |
|
Name |
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| Phone |
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| Fax |
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| Pager |
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| Mobile |
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| Home
Phone |
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| Best
Time to Call |
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| E-Mail
Address |
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General
Company Information |
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Federal Taxpayer ID Number
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| Primary
Business |
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Years
in Operation |
| Ownership
Structure |
Sole Proprietorship
Partnership
Corporation
Other |
| Number
of Employees by Category |
Owners
Active Owners
Full-Time Employees
Part-Time Employees |
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$
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Non-Owner
Employee Payroll |
Does your
company employ sub- contractors?
If
yes, please describe how subcontractors are used.
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$
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If
used, how much does your company spend on subcontractors on an annual
basis? |
| Work
Locations |
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$
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Annual
Gross Income/Sales |
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Workers
Compensation Insurance Information |
| Current
Insurance Carrier |
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Years
With Current Carrier |
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Current
Policy Expiration Date (mo/da/yr) |
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Number
of Employees Covered |
| Limits |
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| Other
Limits |
$
/ $
/ $ |
Any
Waiver of Subrogation?
If yes, explain below.
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| Current
Experience Modifier |
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Any
Claims Past Three Years?
If yes, describe below.
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Job
Classifications
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Additional
Workers Comp Insurance Information |
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Workers Compensation
Insurance Quote Request
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