Workers' Compensation Quote Request - United Insurance Agencies

Workers’ Compensation Quote Request

Workers' Compensation Quote Request

Business Information

Entity Name:

DBA (if applicable):

Type of Entity:

Work Place Address:

City:

State:

Zip:

Mailing Address:

Different From Work Place Address

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip:

Contact Person:

Phone:

Email:

Fax:

Payroll Information

Estimated annual payroll for employees only, not owners or officers. List each class code separately.

Class Code:

Job Description:

Annual Payroll:

# of Employees:

Class Code2:

Job Description2:

Annual Payroll2:

Number of Employees2:

Class Code3:

Job Description3:

Annual Payroll3:

Number of Employees3:

Additional Information

Business Description:

In Business Since:

Employer Federal ID:

Present Insurer:

Policy Number:

Expires On:

Number of Workers' Comp Claims:

(In the last four years)

Ownership Information

Non-Profits: Please List Board Members.

Name:

Title:

% of Ownership:

Excluded:

Name2:

Title2:

% of Owner2:

Excluded2:

Name3:

Title3:

% of Owner3:

Excluded3:

Comments:

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