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WORKERS COMPENSATION
About Your Company
Company Name*
Your First Name*
Last Name*
Email*
Email address (retype)*
Street Address*
City*
Select State*
Zip*
Phone (Day)*
Phone (Evening)
Fax
When would you like to be contacted? No Preference Morning
Afternoon       Evening
Sole Propietorship Partnership Corporation LLC
Association
Do you currently have a Workers Compensation policy? Yes No
  If "Yes", when does your current policy expire?
  If "Yes," who are you currently insured with?
Description of Your Business:
Number of years in business
Number of Locations to be covered
Please list the location address(es):
Please list the names of all owners/officers and specify if they should be included or excluded:
Officer 1:
 Title

Include? Yes No
Officer 2:
 Title

Include? Yes No
Officer 3:
 Title

Include? Yes No
Number of Employees (excluding officers/owners)
Approximate Annual Payroll
Breakdown of Employee Payroll: If your business is a new venture, enter the projected payrolls. Please note that all Workers Compensation policies are subject to an audit.
Class Code or Job Decription Payroll
Has your company had any claims in the last 3 years?
 Yes No
  If "Yes", briefly explain:
Any Comments / Questions?
 
   
 
 
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