Workers Compensation

Workers Compensation insurance is a state mandated insurance coverage to protect employees from work related injuries or death. If you have employees, you are required to carry this coverage.

Customer Information
Company
Contact Person
E-mail_Address
Address
City
State
Zip Code
Home Phone
Work Phone
FAX

Address of Properties (if different from above)
2nd Address (street,city,zip)
3rd Address (street,city,zip)
4th Address (street,city,zip)

Company Information

Type of Company

Individual* Partnership Corporation S-Corporation Other

* If Individual

Owners Name:	Social Security#:
Spouses Name:	Social Security#:

Years in Business

License Number

NCCI Number

Other Rating Bureau
ID Number

Total Gross Receipts

Employees Payroll

Nature of Business operations

Rating Information
Location	Class Code	Categories, Duties	# of Employees	Estimated Annual Remuneration

Individuals to be Included or Excluded
Person	Name	Date of Birth	Title Relationship	Ownership %	Duties	Inc/Exc	Renumeration
1
2
3
4

Prior Carrier Information / Loss History
Year	Carrier	Policy #	Annual Premium	MOD	# Claims	Amount Paid	Reserve

General Information (explain all "yes" answers in remarks)
YesNo	1. Does the applicant own, operate or lease Aircraft/Watercraft?
YesNo	2. Do/have past, present or discontinued operations involve(d) storing, treating, discarging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)
YesNo	3. Any work performed underground or above 15 feet?
YesNo	4. Any work performed on barges, vessels, docks, bridge over water?
YesNo	5. Is applicant engaged in any other type of business?
YesNo	6. Are sub-contractors used?
YesNo	7. Any work sublet without certificate of Insurance?
YesNo	8. Is a formal safety program in operation?
YesNo	9. Any group transportation provided?
YesNo	10. Any employees under 16 or over 60 years of age?
YesNo	11. Any part time or seasonal employees?
YesNo	12. Is there any volunteer or donated labor?
YesNo	13. Any employees with physical handicaps?
YesNo	14. Do employees travel out of state?
YesNo	15. Are athletic teams sponsored?
YesNo	16. Are physicals required after offers of employment are made?
YesNo	17. Any other insurance with this insurer?
YesNo	18. Any prior coverage declined/cancelled/non-renewed (last 3 years)?
YesNo	19. Are employee health plans provided?
YesNo	20. Is there a labor interchange with any other business/subsidiary?
YesNo	21. Do you lease employees to or from other employers?
YesNo	22. Do any employees predominantly work at home?

Contact Information (Name & Phone Number)
Inspection
Accounting Records
Claims Info

Remarks and Comments

Reporting Method
How would you like to receive your free Workers Comp quote?	U.S.Postal E-mail Telephone Fax




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