Please fill out the following questionnaire
as completely as possible. Remember, the more accurate the information
is, the more accurate the quote will be
First Name
Last Name
Company
Name
Street Address
City
State
Zip
Phone
Fax
Email
Please provide us with a thorough description of
your operations.
What type of legal entity is your company?
Sole
Proprietor Partnership Corporation
Have you had workers' compensation insurance for
the past three years?
Yes No
Who is your current workers compensation insurance
carrier?
Have you had any workers compensation claims in the
past three years?
Yes No
If you answered yes to the questions above, please
describe the claim or claims and please be sure to include: When the claim
happened? How much was paid out? What happened?
Please fill out the following table for each class
code that you have.
