Workers Compensation Insurance Quote Request Form

Business Information
Business Name:
Contact Person

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years in Business:
FEIN (Federal Employer ID Number):
NCCI Risk ID (if known):
Type of Business Entity:
If Other, please specify
Requested Effective Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
States of Operation (List all states where employees work)
Do employees travel to other states?
If Yes, specify states:
Number of Full-Time Employees
Number of Part-Time Employees
Estimated Annual Payroll

Additional Information
Do you have a current / previous Workers Comp?
If yes, please provide: Current / Previous Workers Comp Carrier:
Expiration Date of Current Policy:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has any policy been cancelled or non-renewed in the last 3 years?
If Yes, explain
Please list any additional details or coverages needed:
Please attach any relevant documents:Existing Insurance PoliciesLoss Runs (if applicable)Company Brochures or DescriptionsAny Special Coverages or Endorsements requested

Cancelof
RMBIA Service Rep Fill out this form?
Have you read the T&C?
By submitting, I acknowledge that I am requesting an insurance quote and authorize RMB Insurance Agency to obtain my credit and loss history reports.
Should be Empty:

Business Information