Kansas Preferred Insurance Group Work Comp Quote Sheet

Kansas Preferred Insurance Group Work Comp Quote Sheet

913-585-1981 34102 Commerce Dr Ste B De Soto, KS 66018 www.kpigroup.net
Applicant Name:*
Business Name:*
FEIN (Tax ID Number):
Applicant's Date of Birth:
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
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Email
example@example.com
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Type of Business Conducted:*
Effective Date:
Legal Entity Type:
Year Business Started:*
Officer Information:
Name:
Position In the Business:
Percentage Ownership:
Classification
Payroll
Included or Excluded From Coverage

Included CoverageExcluded Coverage
Name:
Position In the Business:
Percentage Ownership:
Classification
Payroll
Included or Excluded From Coverage

Included CoverageExcluded Coverage
Name:
Position In the Business:
Percentage Ownership:
Classification
Payroll
Included or Excluded From Coverage

Included CoverageExcluded Coverage
Name:
Position In the Business:
Percentage Ownership:
Classification
Payroll
Included or Excluded From Coverage

Included CoverageExcluded Coverage
Employee Information:
Number of Full-Time Employees:
Number of Part-Time Employees:
State Located:
Classification:
Zip Code:
Payroll:
Should be Empty:

Officer Information: