Workers Comp Quote

WORKERS COMPENSATION INSURANCE QUOTE TRAINING

*IMPORTANT - Please make sure to get customers correct phone number & email address.

If unaware of what information to put in one of the boxes please put N/A.
- AGENT INFORMATION SECTION -

Please submit your information below (Not Customers)
Agent Name *
Store Name *
IMPORTANT: Do NOT use an " @ " instead use a " - " Example: Airport-51st
Agent Email *
- CUSTOMER INFORMATION SECTION -

Please submit Customers Information Below
Insured First and Last Name*
DBA: (Doing Business As)
Phone Number *
Email*
Preferred method of contact for customer*

PhoneEmailText
Address*
Example: 2700 S IH 35 Frontage Rd Austin, TX 78704
Date of Birth
Type Of Business?*
Business Gross For Previous Year:
How Many Employees Do You Have?
How Much Did You Spend In Payroll Last Year?
What Percent Of Work Is Residential?
What Percent Of Work Is Commercial?
How Many Years Of Experience Doing Current Job?
How Long Has The Business Been Open?
Do You Have Prior Insurance?

YesNo
Have You Had Any Claims In The Last 3 Years?

YesNo
If Yes, Please List The Date, Carrier, And Pay Out In The Claim:
Is Any Of The Work Subcontracted?

YesNo
If Yes, Please Explain What Percentage Is Subcontracted:
Does The Subcontractors Have Their Own Insurance?

YesNo
Type Of Liability Coverage:

$500,000$1,000,000$2,000,000Other
Additional Information
If any additional information please list here
Should be Empty:

- AGENT INFORMATION SECTION -