Workers Compensation InsuranceWork Comp Insurance QuoteBusinessBusiness InsuranceMain PageContact Us Work Comp Quote Work Comp Quote Name First Last Business NameMailing Address Street Address Business Address if Different from Above City State / Province / Region ZIP / Postal Code PhoneEmail Proposed Work Comp Start DateMonth /Year Business Started (XX / XXXX)Nature of BusinessNumber of Employees (Full Time)SelectNone1234567891011121314151617181920212223242526 or moreNumber of Part Time EmployeesSelectNone1234567891011121314151617181920212223242526 or moreEstimated Annual Gross RevenueEstimated Annual Employee PayrollDo you have a WCIRB number? If Yes, What is your WCRIB number?Do you have an experience mod number? If yes, What is exp. mod number?Federal Employee Identification Number (FEIN) or SSI numberLegal EntitySelectSole ProprietorPartnershipS CorpCorporationLLCJoint VentureOtherIf Other - DescribeOwners / Officers Name (Owner/ Officer #1) First Last Title Owner /Officer #1SelectOwnerPartnerPresidentVice PresidentTreasurerSecretaryMemberPercentage of Ownership (Owner/ Officer #1)Included / Excluded (Owner/ Officer #1)SelectIncludedExcludedAdd Officer # 2SelectNoYesOwners / Officers #2 Name First Last Title Owner /Officer #2SelectOwnerPartnerPresidentVice PresidentTreasurerSecretaryMemberPercentage of Ownership (Owner/ Officer #2)Owner / Officer # 2 Included / ExcludedSelectIncludedExcludedAdd Officer # 3SelectNoYesOwners / Officers # 3 Name First Last Title Owner /Officer # 3SelectOwnerPartnerPresidentVice PresidentTreasurerSecretaryMemberPercentage of Ownership (Owner/ Officer #3)Owner / Officer # 3 Included / ExcludedSelectIncludedExcludedAdd Officer # 4SelectNoYesOwners / Officers # 4 Name First Last Title Owner /Officer # 4SelectOwnerPartnerPresidentVice PresidentTreasurerSecretaryMemberPercentage of Ownership (Owner/ Officer #4)Owner / Officer # 4 Included / ExcludedSelectIncludedExcludedInspection Contact -Name First Last Inspection Contact PhonePrior Work Comp (in Last 4 Years)SelectNo Prior Work Comp InsuranceYesCurrent Annual PremiumYear (last Year) CoverageSelect2015201420132012201120102009200820072006200520042003200220012000Work Comp Insurance Company Name (1)Year (Two Years Ago) CoverageSelect2015201420132012201120102009200820072006200520042003200220012000Work Comp Insurance Company Name (2)Year (Three Years Ago) CoverageSelect2015201420132012201120102009200820072006200520042003200220012000Work Comp Insurance Company Name (3)Year (Four Years Ago) CoverageSelect2015201420132012201120102009200820072006200520042003200220012000Work Comp Insurance Company Name (4)Year (Five Years Ago) CoverageSelect2015201420132012201120102009200820072006200520042003200220012000Work Comp Insurance Company Name (5)Any Losses in the Past 5 YearsSelectNoYesNumber of Losses in past 5 yearsSelect012345 or More Please phoneProvide Date, Description of Loss 1, Amount of LossProvide Date, Description of Loss 2, Amount of LossProvide Date, Description of Loss 3, Amount of LossProvide Date, Description of Loss 4, Amount of LossPlease provide / upload Loss Runs for Past 5 YearsMax. file size: 256 MB.
