Quote: Workers Compensation

Company Name:*
Contractors License #:*
FEIN: Employer ID #, 9 Digit:*
What type of work do you do?:*
Annual Sales Receipts:*
Subcontractor Costs:*
How Many Total Employees:*
How many full time employees:*
How many part time employees:*
Annual Payroll: Projected:*
Worked performed over 15 feet high:*
Work performed below 6 feet underground:*
Current Insurance In Place:*
Do you have "loss runs" for last 4 years prior work comp:*
Contact Name:*
Contact Phone:
-
E-mail:*
Effective Date Requested:*
Extra Details:

If you have prior workers compensation coverage in last 4 years, current dated (90 days) “loss run’s” will need to be furnished for possible quotation. You can order them from your prior insurance companies. All insurance companies require loss runs to offer possible quotation. For assistance and a loss run request form, please specify in “Extra Details” section of field above.