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Workers Compensation

* = Required Information

This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Workers insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.

Work Comp Fact Finding Questions

Of the following, what is the primary reason for quote request?	Requesting More Info State Required Employee Protection

In the order of importance, what is most important to you?	Price Service Proper Coverage

Approximately when was the last time you did a review with your agent?	Within the year Over 2 years ago Over 5 years ago Never

Would you be interested in going to higher deductibles to reduce your premium?	Yes No

In the event of a lawsuit, accident, or judgment would you want to:	Maximize Protection Assume Some Risk

In the event of an untimely death, is it important to you that you're surviving spouse and/or children maintain the quality of life you currently have together without debt?	Yes No

Would you be interested in combining your commercial insurance for additional savings?	Yes No

If health insurance is provided for employees, would you like to save money?	Yes No Requesting More Info

Has your current company/agent failed to meet your expectations in any way?	Yes No

What else must I do to earn your business?

Contact Information

Contact Name

Business Name

Address

City

State

Zip Code

Business Phone Number

Primary Phone Number to Reach You

Fax

Email *

Contact Me During

Current Coverage Information

Current Insurance Company

Losses and Claims for the Last 5 years	Yes No

If yes, what is the date, amount paid and description of each loss or claim

Total Annual Premium

Liability Limit

Business License Number

License Type

Years Operated

Other Business Names

Underwriting Information

Nature of Business

Type of Business

Number of Owners

Number of Employees

Payroll of Owners

Payroll of Employees

Annual Gross Receipts

Other Business Names

Open 24 Hours

Deep Frying

Manufacturing

Propane Tank Filling

Describe the nature of your business and ANY unusual exposures.

Payroll

Employee Group 1 Payroll Information
Class Code
Payroll Rate
Annual Payroll

Employee Group 2 Payroll Information
Class Code
Payroll Rate
Annual Payroll

Employee Group 3 Payroll Information
Class Code
Payroll Rate
Annual Payroll

Employee Group 4 Payroll Information
Class Code
Payroll Rate
Annual Payroll

Employee Group 5 Payroll Information
Class Code
Payroll Rate
Annual Payroll

Employee Group 6 Payroll Information
Class Code
Payroll Rate
Annual Payroll

Additional Information

Comments/ Requests/ Additional Information