Agency & Contact InformationAgency NameAgency Phone NumberAgency Fax NumberName of Contact First Last Contact's Email Owner's InformationBusiness Type*IndividualPartnershipCorporationLLCNot For ProfitOwner / 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 OwnershipIncluded / Excluded Policy & Rating InformationBusiness Name:*Federal ID#*Years In Business*Business' Phone Number*Proposed Effective Date* Date Format: MM slash DD slash YYYY Employer's LiabilityEach AccidentDisease-Policy LimitDisease-Each EmployeeLocations(Click on the + to add additional locations)StreetCityCountyStateZipType of Work PerformedNumber of Full-Time EmployeesNumber of Part-Time EmployeesEst. Annual Payroll Has there been a cancellation / lapse in coverage due to non-payment of premium in the past 18 months?YesNoAre employee health plans provided?YesNoCurrent year experience modification*Previuos year experience modification*Any tax liens or bankruptcy within the last 5 years?*YesNoDoes the company have work comp coverage currently?*YesNoHow Many Years*Date* Date Format: MM slash DD slash YYYY Has company had any claims in the past 3 years?YesNo***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 918-336-2178Additional Remarks