Workers Compensation Quote Form

Agent Name: Phone:

Business Name: Effective Date for Quote:

Premises Address:

City: State: ZIP Code:

Contact Name: Phone:

Federal Employer's ID#:

Type of Business:
Other:

Year this business started under the current ownership:

Years of total overall experience the owner has in this business type:

Losses past 3 years:

# of full-time employees: # of part-time employees: # of locations:

Estimated Total Annual Payroll: $ Experience Mod (if any, per policy):

Do you require increased limits beyond 100/500/100? If so, please state limits needed:

Employee Information:

Employee Type Job Description Class Code Annual Payroll Estimate
1
2
3
4
5

Officers / Partners / Owners Information:

Principal Name Title Class Code Exclude from Coverage? Yes or No
1
2
3
(optional)