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Workers Compensation
* = Required Information
This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Workers insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
 
Work Comp Fact Finding Questions
Of the following, what is the primary reason for quote request? Requesting More Info 
State Required 
Employee Protection 
In the order of importance, what is most important to you? Price
Service 
Proper Coverage 
Approximately when was the last time you did a review with your agent? Within the year 
Over 2 years ago 
Over 5 years ago 
Never 
Would you be interested in going to higher deductibles to reduce your premium? Yes 
No 
In the event of a lawsuit, accident, or judgment would you want to: Maximize Protection 
Assume Some Risk 
In the event of an untimely death, is it important to you that you're surviving spouse and/or children maintain the quality of life you currently have together without debt? Yes 
No 
Would you be interested in combining your commercial insurance for additional savings? Yes 
No 
If health insurance is provided for employees, would you like to save money? Yes 
No 
Requesting More Info 
Has your current company/agent failed to meet your expectations in any way? Yes 
No 
What else must I do to earn your business?
Contact Information
Contact Name
Business Name
Address
City
State
Zip Code
Business Phone Number
Primary Phone Number to Reach You
Fax
Email *
Contact Me During
Current Coverage Information
Current Insurance Company
Losses and Claims for the Last 5 years Yes 
No 
If yes, what is the date, amount paid and description of each loss or claim
Total Annual Premium
Liability Limit
Business License Number
License Type
Years Operated
Other Business Names
Underwriting Information
Nature of Business
Type of Business
Number of Owners
Number of Employees
Payroll of Owners
Payroll of Employees
Annual Gross Receipts
Other Business Names
Open 24 Hours
Deep Frying
Manufacturing
Propane Tank Filling
Describe the nature of your business and ANY unusual exposures.
Payroll
Employee Group 1 Payroll Information
Class Code
Payroll Rate
Annual Payroll
Employee Group 2 Payroll Information
Class Code
Payroll Rate
Annual Payroll
Employee Group 3 Payroll Information
Class Code
Payroll Rate
Annual Payroll
Employee Group 4 Payroll Information
Class Code
Payroll Rate
Annual Payroll
Employee Group 5 Payroll Information
Class Code
Payroll Rate
Annual Payroll
Employee Group 6 Payroll Information
Class Code
Payroll Rate
Annual Payroll
Additional Information
Comments/ Requests/ Additional Information