Worker's Compensation Proposal- Quick Information Sheet

Worker's Compensation Proposal- Quick Information Sheet

McLaren and Associates
Business Name
Point Person for Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Head Officer

First NameLast Name
Title
Names of Officers to Exclude
Business Ownership Structure (LLC, Scorp, Corp, etc.)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Business Website Address
FEIN
Year Business was Established
Number of FT employees
Number of PT employees
Annual Revenue
Annual Payroll less excluded officers
What limits do you prefer? (i.e 500/500/500, 1000/1000/1000)
Any prior Work Comp Losses?
If so, what year(s), type of loss and amount paid for each
MOD rating, if known
Do you have the latest modification worksheet?
Do you have the declarations page for your current policy?
Do you have any business autos? If so, please list the year, make and model.
Current General Liability Carrier
Current GL Policy Expiration Date
Brief description of what your company does
McLaren and Associates

(714) 968-4100- California

(520) 277-0630- Arizona

(850) 701-3801- Florida

john@mclarenandassociates.com

LIC # 0E44270
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