Workers' Comp Questionnaire

Workers' Comp Questionnaire

Workers' Compensation Insurance
Insurance Agent:*
Please select the name of your RealCare agent
1. Legal Business Name:*
DBA:*
Contact Name:*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Do you have multiple locations?*

YesNo
Addresses of all additional locations:
3. Type of Ownership: *
(corp, individual, etc.)
4. FEIN (EIN):*
Federal Employer Identification Number
5. Date Business Started:*
Date
6. Years of Industry Experience:*
7. Number of Owners and/or Officers:*
8. Number of FULL-TIME Agents and/or Employees (including 1099):*
Please include all full-time agents, employees, and 1099 contractors working 35+ hours per week.
9. Number of PART-TIME Agents and/or Employees (including 1099):*
Please include all part-time agents, employees, and 1099 contractors working less than 35 hours per week.
10. Do you perform Property Management Services?*

YesNo
If yes to #10, please describe the services provided and which members of the firm are involved in property management.
If you provide Property Management services, please describe.
11. Projected Annual 1099 Commission and/or Payroll:*
12. What percentage of the above 1099 Commission and/or Payroll is for Property Management Services?*
%
13. Is the Owner Excluded from Workers’ Compensation Coverage?*

YesNo
14. Does the firm currently have Workers’ Compensation coverage?*

YesNo

If Yes to #14, please provide Loss Runs for up to four previous years:

Rows	Carrier	Policy Dates	Premium	Payroll	# of Losses
Current Year
Last Year
Previous Year
Previous Year

15. Any prior coverage declined, cancelled or non-renewed in the past three years?*

YesNo
16. List any claims within past 3 years:
Please describe any Workers' Comp Insurance claims you've had within the past three years
Should be Empty: