Quote Form - Workers Compensation Insurance for Contractors
Fields marked * are required.
Contractor License Number: *
Insured / Contact: *
Company Name: *
Phone: *
Fax:
Email: *
Policy Term Requested:
Social Security No. or Federal Tax ID:
 
Mailing Address Premise Address (if different)
Address
* 		Address
City
* 		City
State
* 		State
Zipcode
* 		Zipcode
 
Job Classification: Expected Salary: Avg. Hourly Wage:

 

Please type Job Class here if not listed:
 $ $

 

Please type Job Class here if not listed:
 $ $

 

Please type Job Class here if not listed:
 $ $

 

Please type Job Class here if not listed:
 $ $
 
Have you had any worker's compensation claims?
If "Yes", please give details:
 
Do you currently have coverage?
If "Yes", provide loss runs from your prior carriers and include Company & Policy number:
How many years of continuous coverage have you had?
Indicate which type of business you operate?

 

Other:
Owner Name (please complete for all owners): Date Of Birth: % Ownership:
%
%
%
 
Number of years in business:
If less than 4 years in business, number of years in the trade:
 
Describe your operations:
Percentage of New Construction:
Residential:
% 		Commercial:
% 		Industrial:
%
Percentage of Remodeling:
Residential:
% 		Commercial:
% 		Industrial:
%
Percentage of Repair Work:
Residential:
% 		Commercial:
% 		Industrial:
%
 
Number of Employees:
Full-time:
 Part-time:
 Seasonal:
 
Additional Comments:
 

 

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