Workers' Comp Questionnaire
Workers' Compensation Insurance
Insurance Agent:
*
Please Select
Susie Pusich
Kristin Fall
Rebecca Squires
Melissa Isaiyas
I don't have an agent
I don't know
Please select the name of your RealCare agent
1. Legal Business Name:
*
DBA:
*
Contact Name:
*
First Name
Last 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
City
State / Province
Postal / Zip Code
Location Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Do you have multiple locations?
*
Yes
No
Addresses of all additional locations:
3. Type of Ownership:
*
Please Select
Corporation/LLC
Individual/Sole Proprietor
Partnership
Independent Contractor
Other
(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?
*
Yes
No
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?
*
Yes
No
14. Does the firm currently have Workers’ Compensation coverage?
*
Yes
No
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?
*
Yes
No
16. List any claims within past 3 years:
Please describe any Workers' Comp Insurance claims you've had within the past three years
Submit
Should be Empty: