Workers Compensation Form

Workers Compensation Questionnaire

Please fill the form accurately for better assistance
Name

First NameLast Name
Business Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Describe Business
Describe Business in Detail

- Name
  
  First NameLast Name
- DOB
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate of Birth
- % of Ownership
- Name
  
  First NameLast Name
- DOB
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate of Birth
- % of Ownership
- Name
  
  First NameLast Name
- DOB
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate of Birth
- % of Ownership
- Name
  
  First NameLast Name
- DOB
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate of Birth
- % of Ownership
- SSN or FEIN #

Type of Business

Other
If Other, describe:
Year Business Established
Years Experience in Field
Hours of Operation
Days of Operation
Current Insurance and Coverage
If any claims, how much was paid out?

Number of Employees
Number of Full-Time Employees
Number of Part-Time Employees
- Employee Type/ Classification
- Payroll of Employee(s)
- Employee Type/ Classification
- Payroll of Employee(s)
- Employee Type/ Classification
- Payroll of Employee(s)
- Employee Type/ Classification
- Payroll of Employee(s)
- Employee Type/ Classification
- Payroll of Employee(s)
- *** Will need to get Loss Runs ordered from current carrier ***
- Should be Empty: