Work Comp Quote Form
Business Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Website
Legal Entity
*
Individual
Partnership
Corporation
S-Corporation
LLC
Nature of Business/ Description of operations:
*
FEIN
*
Federal Employee ID #
State Employer ID
Years in Business
*
MM/DD/YYYY
Date Business started
*
MM/DD/YYYY
Years' Experience
*
Current Work Comp Carrier
Name of company
Expiration Date
MM/DD/YYYY
Policy Number
Any Claims in the past 5 years?
*
Yes
No
Number of claims
Amount paid out
Loss Run Report
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Loss history report
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of
Owner Name
*
First Name
Last Name
Date of birth
*
Owner date of birth
Title
*
Owner title
Percentage of ownership
*
Duties
*
Owner Duties
Payroll
*
Owner Payroll
Included or Excluded on Work Comp
*
Owner excluded or excluded
2nd Owner Name
First Name
Last Name
Date of birth
2nd owner date of birth
Title
2nd Owner title
Percentage of ownership
2nd owner % ownership
Duties
2nd Owner Duties
Payroll
2nd Owner Payroll
Included or Excluded on Work Comp
2nd Owner excluded or excluded
Job Description 1 and class code (found on dec page of policy)
*
Number of Full Time
*
For job description 1
Number of Part Time
*
For Job Description 1
Total Payroll
*
For Job Description 1
Job Description 2 and class code (found on dec page of policy)
Number of Full Time
For job description 2
Number of Part Time
For Job Description 2
Total Payroll
For Job Description 2
Job Description 3 and class code (found on dec page of policy)
Number of Full Time
For job description 3
Number of Part Time
For Job Description 3
Total Payroll
For Job Description 3
Job Description 4 and class code (found on dec page of policy)
Number of Full Time
For job description 4
Number of Part Time
For Job Description 4
Total Payroll
For Job Description 4
Policy copy
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Cancel
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Submit
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