Worker's Compensation Insurance Premium Indication Questionnaire

Contact Information
 
Name of Business:
 
 
Principal Contact Name:
 
 
Street Address:
 
 
Mailing Address:
 
 
City:
State:
  
Zip:
 
Phone:
Fax:
 
Email Address:
         

Business Activities
 
Type of Business:
Sole Proprietor    S-Corp     LLC     Other
Other:
  
 
Description of Business/Services:
          
 
Primary State Where Business Is Located?
         

Payroll Information
Do not include payments to Owners or Sub-Contractors unless coverage is desired or required for them.  
Annual Gross Payroll:   $
   
Employee Classification and Payroll by State:
    
Classification
(Example: Tax Preparer, Administrative Assistant, etc. )
No. of Employees
Annual Payroll
State
$
$
$
$

Coverage Information
Do you currently carry Worker's Compensation Insurance?
Yes    No
 
Current Carrier:
Expiration Date:
/ / (mm/dd/yyyy)
Premium:
Have you had any losses in the past five years?
Yes    No
If yes please provide the date, description and amount paid below

Signature
 

IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED IT WILL ATTACH TO THE POLICY.
I understand that the final premium will be rounded to the next dollar. I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my Professional Liability application.
 

The Electronic Signature Process (E-signature) provides you with a faster and more convenient way to process your application. Filling out this text box is the equivalent of signing your name.
 
E-Signature
(Please type your name)