Payroll Workers Compensation Insurance

PRIVACY NOTICE: WE DO NOT DISCLOSE, SELL, OR TRANSFER ANY INFORMATION ABOUT OUR VISITORS. 

YOUR INFORMATION IS SHARED WITH INSURANCE RELATED ENTITIES FOR THE SOLE PURPOSE OF UNDERWRITING & QUOTING.

ABOUT YOU

Your Name:

Title/Position:

Email:

Phone:

     Fax: 

ABOUT YOUR BUSINESS

Company Name:

Years in Business:

          Business Type:  Select Individual Partnership LLC S-Corp C-Corp Other     

Complete Address:

Address City, State Zip

Employee Count:

          Fed Tax ID:  social security if no Fed ID Number

Gross Annual Payroll:

estimated            Work Comp Mod: if known

If Known Class Code 1:

          Estimated Payroll for Class Code 1: 

Class Code 2:

          Estimated Payroll for Class Code 2: 

Class Code 3:

          Estimated Payroll for Class Code 3: 

Additional Codes/Payroll:

if any

Owner Information:

1) Owner Names 2) Include or Exclude for Coverage

Any Claims Last 3 Years:

(if yes, please describe)

Please Describe

Your Business:

Please List Any Other Lines of Coverage Needed:

Do You Use a Payroll Company:

Yes No     If yes, Which Company:  

Current Carrier:

     Current Premium:  

Remarks/Needs/Comments:

if applicable: I-Shop Broker:

optional

OPTIONAL FILES & DOCS

*Please e-mail any policy requirements, current policy pages, workmans comp loss runs, NCCI mod worksheet, etc. that you believe might help us provide the best possible quotes.

(pdf, xls, doc, tiff, jpeg)

only please: