Workers Compensation Policy Request

Workers Compensation Policy Request

Please complete as much as possible for the best results
List the Agents name you prefer to work with
If unknown, please enter "Lisa"
Your Company Name
Or your name if the business is not currently established
EIN/Tax ID Number
If available
Website
If available
Your Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Percentage of ownership
If not 100%, please provide names of additional owners and their date(s) of birth:
Please include all owners and percentage of ownership
Please describe your business
How many years have you been in business?
How many years experience do you have in this line of work?
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address if different
Any Additional Locations
Annual Gross Revenue
Will any of the owners be included in the policy
Number of Full Time Employees
Including owner and all officers
Number of Part Time Employees
Please describe the employees responsibilities and related annual payroll
Example: 2 Servers- $30,000 per year, 1 Clerical $20,000 per year
Annual Payroll without Owner(s)
Required for workers comp if applicable
Total Annual Payroll with Owner(s)
Please describe the safety measures you have in place for your employees:
Current WC Insurance Provider
If none, type n/a
Desired Effective Date

MonthDayYear
Date
Would you like us to quote any other policies for you?
What else would you like to share to help us prepare the best policy for you?
If needing Commercial Auto, please include all driver information here including driving license numbers
How did you hear about us?
Feel free to upload your current policy or declaration pages if available

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Thank you for choosing us to assist you with your insurance needs. We are excited to provide you superior service and value.

Dodge Insurance Agency

DodgeAgency@outlook.com

702-827-6007
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