subject_line
Workers Compensation Quote Request
COMPANY INFO
Company Name
*
Name of person completing this form
*
Best Point of Contact for this claim (Name / Phone / Email):
*
Website
Owner / Decision Maker
Primary Point of Contact
*
E-mail
*
Phone
*
Years in Business
Tax ID
*
Legal Entity
Individual
Corporation
Partnership
LLC
Business Address
Mailing Address
Contractors License (if applicable):
Current X-MOD
Current Carrier
Current Policy Expiration Date:
Current Carrier / History / Level of Satisfaction:
Current Carrier / History / Level of Satisfaction:
Provide a list of owners and percentage of ownership:
Name 1:
Title:
Percent owned by Applicant:
Name 2:
Title:
Percent owned by Applicant:
Name 3:
Title:
Percent owned by Applicant:
CLASS CODE INFORMATION
Class Code 1
Class Code
Description
Nunber of Employees
Estimated Annual Payroll
Class Code 2
Class Code
Description
Number of Employees
Estimated Annual Payroll
Class Code 3
Class Code
Description
Number of Employees
Estimated Annual Payroll
Class Code 4
Class Code
Description
Number of Employees
Est. Annual Payroll
Class Code 5
Class Code
Description
Number of Employees
Est Annual Payroll
Class Code 6
Class Code
Description
Number of Employees
Est Annual Payroll
Class Code 7
Class Code
Description
Number of Employees
Est Annual Payroll
Class Code 8
Class Code
Description
Number of Employees
Est Annual Payroll
Class Code 9
Class Code
Description
Number of Employees
Est Annual Payroll
Class Code 10
Class Code
Description
Number of Employees
Est Annual Payroll
ADDITIONAL CLASS CODES / PAY ROLL INFORMATION:
DESCRIPTION OF OPERATIONS
*
GENERAL INFORMATION
Claims Experience
How do you currently pay your premium?
How do you currently process your payroll?
Existing Safety Programs
Current Hiring Practices
% Union Labor
Number of Waivers of Subrogation Requested Per Year
Percentage of Work Subcontracted
Type of Work Subcontracted
Maximum Height Exposure
Maximum Depth Exposure
Any Group Transportation
Number of Company Trucks / Drivers (if any)
Percentage of Commercial / Residential / Industrial Work
Commercial
Residential
Industrial
0/100 points
Notes / Additional Info
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