Workers Compensation

~ 5-10 Minute Quote Worksheet

 
1. Company Name:
Contact:
DBA:
Phone:
          Fax:
E-mail:
   

2. Are employees health plans provided? (If YES, answer A-C)

Yes No
A. Name of Health Care Provider
B.% of employees/agents participating:
%
C. % of employer contribution:
%
   
3. # of Full-Time employees/agents:
  # of Part-Time employees/agents:
# of employees/agents are:
Increasing Decreasing Stable
# of 1099 agents:
   # of W-2 employees:
 
4. Has ownership of the business changed in the past year?
Yes No
   
5. Has the business or any principal of the business declared bankruptcy?
Yes No
6. Federal Tax ID Number (FEIN) for this business:
 
7. Total # of locations:
   
8. Addresses of locations:
   

9. Projections for the upcoming year: 

FT employees:    PT employees:
  Estimated Annual Remuneration: $
   
10. Building construction type :
 Wood Frame Tilt-up Concrete Masonry
# floors:
Hours of operation:
     # of daily shifts:
   
11. Prior Carrier Information:
 
Renewal Date:  
('05-'06): Name of Carrier:
Policy #: Annual Premium: $
  Annual Payroll: $   # of Claims:
   
('04-'05): Name of Carrier:
Policy #: Annual Premium: $
  Annual Payroll: $   # of Claims:
   
('03-'04): Name of Carrier:
Policy #: Annual Premium: $
  Annual Payroll: $   # of Claims:
   
12. Owners to be EXCLUDED:
Please enter: Name; Title; % of Ownership; Duties