Workers Compensation Insurance

Proposed Effective Date

Your insurance should start on?

Business Information

First Name Last Name
Business Name

Phone Number Address
Fax Number City State Zip

Current Insurance Information

Current Insurance Carrier Expiration Date Premium Amount
Any losses in the last 3 years? # of claims Claim amount paid
MOD Factor Describe the type of Coverage you currently have

Prior Carrier Info

Insurance Carrier How many years with Premium Amount
MOD Factor # of claims Claim amount paid

About Your Business

# of Full-time # of Part-time Years in Business Business Type
Owner's Name Fed Tax ID License Type License #
# of locations Annual Gross Payroll / mo Square Footage
Please describe your business

Owners / Partner / Officers

Name Date of Birth Title Ownership %

Payroll Information

Class Codes Employee Duties Annual Payroll Hourly Wage

General Information

Do you offer safety programs?
Do offer health benefits to majority of employees?
Do employ any minors (under 18)?
Operation all/part of exist. business purch/acq?
Do you use subcontractors?
Use any equipment that bends/shapes/forms?
Are athletic teams sponsored?
Been a lapse in coverage during past 12 months?
Any work above 15 feet?
Had a bankruptcy in past 7 years?
Are a member of any trade organizations?