Workers Comp | Standard Lines Services

Agency & Contact Information

Agency Name

Agency Phone Number

Agency Fax Number

Name of Contact

First Last

Contact's Email

Owner's Information

Business Type*

Owner / Officer(s) Names:*

Please list all Owners &/or Officer, their % of ownership, and whether they are included or excluded.

(Click on the + to add additional names.)

Name	% of Ownership	Included / Excluded

Policy & Rating Information

Business Name:*

Federal ID#*

Years In Business*

Business' Phone Number*

Proposed Effective Date*

Employer's Liability

Each Accident

Disease-Policy Limit

Disease-Each Employee

Locations

(Click on the + to add additional locations)

Street	City	County	State	Zip	Type of Work Performed	Number of Full-Time Employees	Number of Part-Time Employees	Est. Annual Payroll

Has there been a cancellation / lapse in coverage due to non-payment of premium in the past 18 months?

Yes
No

Are employee health plans provided?

Yes
No

Current year experience modification*

Previuos year experience modification*

Any tax liens or bankruptcy within the last 5 years?*

Yes
No

Does the company have work comp coverage currently?*

Yes
No

How Many Years*

Date*

Has company had any claims in the past 3 years?

Yes
No

***Please attach 3 years loss history reports***

Even if company has no losses, loss reports or a no loss letter on company letterhead, they are still required for quoting purposes and potential additional discounts. You may also fax these to 918-336-2178

Additional Remarks