Workers Compensation Data Sheet Submission Form

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For a Workers Compensation and/or Auto, Property, General & Umbrella Liability quote, please complete and submit the following form:
Business Name
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Applicant Information
1. Address

Street Address

Street Address Line 2

CityState

Zip Code
2. Description of Operations
3. Years in Business
4. Has applicant experienced any losses in the last three years?
If Yes, please attach loss run reports here:

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Workers Compensation Information

5. Class Code and Payroll

If you have more than five entries, please attach a document with your full list here:

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6. NCCI Experience Mod
7. Does applicant have employees that work above 30 feet or below grade level?
Note: if you are only interested in a workers compensation quote you can skip the following questions and click "submit"
General Liability Information

8. Class Code and Payroll

If you have more than five entries, please attach a document with your full list here:

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9. Each Occurrence Limit/General Aggregate Limit
10. Does applicant need a blanket additional insured coverage endorsement?
Business Auto Information

11. Vehicle Information

If you have more than five entries, please attach a document with your full list here:

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12. Combined Single Liability Limit
13. Does applicant need hired and non-owned auto coverage?
14. Umbrella Liability Limit
Should be Empty:

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