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*
E-mail
example@example.com
Describe Business*
Describe Business in Detail

Business Owner Information
Name

First NameLast Name
DOB

MonthDayYear
Date of Birth
% of Ownership
Name

First NameLast Name
DOB

MonthDayYear
Date of Birth
% of Ownership
Name

First NameLast Name
DOB

MonthDayYear
Date of Birth
% of Ownership
Name

First NameLast Name
DOB

MonthDayYear
Date of Birth
% of Ownership
SSN or FEIN #*

Type of Business*

IndividualPartnershipCorporationOther
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 Information
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: