Workers Compensation Insurance

Your insurance should start on?

First Name	Last Name
Business Name

Phone Number	Address
Fax Number	City	State	Zip
		CA AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Email

Current Insurance Carrier	Expiration Date	Premium Amount
Any losses in the last 3 years?	# of claims	Claim amount paid
Select One Yes No
MOD Factor	Describe the type of Coverage you currently have

Insurance Carrier	How many years with	Premium Amount
MOD Factor	# of claims	Claim amount paid

# of Full-time		# of Part-time		Years in Business		Business Type
						Select One Wholesaler Retailer Manufacturer Contractor Service Other
Owner's Name		Fed Tax ID		License Type		License #
# of locations		Annual Gross		Payroll / mo		Square Footage
Please describe your business

Name	Date of Birth	Title	Ownership %

Class Codes	Employee Duties	Annual Payroll	Hourly Wage

Do you offer safety programs?	Select One Yes No
Do offer health benefits to majority of employees?	Select One Yes No
Do employ any minors (under 18)?	Select One Yes No
Operation all/part of exist. business purch/acq?	Select One Yes No
Do you use subcontractors?	Select One Yes No
Use any equipment that bends/shapes/forms?	Select One Yes No
Are athletic teams sponsored?	Select One Yes No
Been a lapse in coverage during past 12 months?	Select One Yes No
Any work above 15 feet?	Select One Yes No
Had a bankruptcy in past 7 years?	Select One Yes No
Are a member of any trade organizations?	Select One Yes No
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