Worker's Compensation Quote Form

Page Insurance, Ltd

102 Boston Street

Guilford, CT 06437

(203) 453-5258

info@pageins.com
Business Name:
Your Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
E-mail:
Type of Business:*
Website:
Federal Employer ID No.:
Mod:
Mod Effective Date:
Payroll Information
General Information
1. Does applicant own, operate or lease Aircraft/watercraft?

YesNo
2. Have past, present or discontinued operations involved storing, treating, discharging, applying, disposing or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)

YesNo
3. Any work performed underground or above 15 feet?

YesNo
4. Any work performed on barges, vessels, docks, or bridges over water?

YesNo
5. Is applicant engaged in any other type of business?

YesNo
6. Are sub-contractors used? (if yes % of work subcontracted)

YesNo
7. Any work sublet without certificates of Ins.?

YesNo
8. Is a formal safety program in operation?

YesNo
9. Any group transportation provided?

YesNo
10. Any employees under 16 or over 60 years?

YesNo
11. Any seasonal employees?

YesNo
12. Is there any volunteer or donated labor?

YesNo
13. Any employees with physical handicaps?

YesNo
14. Do employees travel out of state?

YesNo
15. Are athletic teams sponsored?

YesNo
16. Are physicals required after offers of employment are made?

YesNo
17. Any other insurance with this insurer?

YesNo
18. Any prior coverage declined/canceled /non-renewed last 3 years?

YesNo
19. Are employee health plans provided?

YesNo
20. Is there a labor interchange with any other business/ subsidiary?

YesNo
21. Do you lease employees from other employers?

YesNo
22. Do any employees predominantly work at home?

YesNo
Any Claims In The Past (3) Years:
Current Carrier:
Policy Number:
Premium:
Should be Empty:

General Information