Workers Compensation Questionnaire
Please fill the form accurately for better assistance
Name
*
First Name
Last Name
Business Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Describe Business
*
Describe Business in Detail
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Business Owner Information
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date of Birth
% of Ownership
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date of Birth
% of Ownership
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date of Birth
% of Ownership
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date of Birth
% of Ownership
SSN or FEIN #
*
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Type of Business
*
Individual
Partnership
Corporation
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?
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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 ***
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