Workers Compensation Quote

Agency & Contact Information

Agency Name*

Agency Phone Number*

Agency Fax Number

Name of Contact*

First Last

Contact's Email*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Insured’s Information

Business Type*

Business Name:*

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

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Business Phone Number*

Business Email Address*

FEIN or SSN*

Years In Business*

Requested Effective Date (mm/dd/yy)*

Employer's Liability

Limits (Each Accident, Policy Limit, Each Employee)*

$100,000 / $500,000 / $100,000
$500,000 / $500,000 / $500,000
$1 Million / $1 Million / $1 Million

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*

Previous 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

Expiration Date*

How Many Years*

Anniversary Date*

Has company had any claims in the past 3 years?*

Yes
No

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

If a loss has occurred within the last 3 years, loss runs are required prior to quoting. Even if company has no losses, loss reports or a no loss letter on the company letterhead are required for quoting purposes and potential additional discounts. You may also fax these to 918-336-2178.

Drop files here or

Max. file size: 16 MB.

Additional Remarks

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Workers Compensation Quote Request

Agency & Contact Information

Insured’s Information

Employer's Liability