Company Name     

Federal ID (FEIN)   

Contact Name        

Contact phone             Fax   

Contact email              Website

Business address  

Number of employees   Office >      Field >   

Year business established YYYY 

Annual Gross Sales    This year        Last year   

If you use a Payroll Service please check here and advise 

Name of Payroll Service        Annual Cost   

IMPORTANT NOTE: Thank you for completing this request from. In addition to the information you have provided we also need you to fax or email the following documents to us-

1. Your most recent Workers Compensation insurance policy Declaration Page. This is the first page that shows your company name, address and type of business and the effective and expiry date of your coverage.

2. The policy rating schedule that shows the class code(s) and annual payroll projections for each class of employee. This will be close to the beginning of your policy.

3. Workers Compensation Loss Runs for the last 3 years. If you do not have them we can help you get them.

Important note: Please review entire submission carefully before submitting this form as false information may void your insurance. Submitting this form does not bind you to purchase the insurance or any Insurer to accept the risk, however it is agreed that the information submitted shall be the basis of the quotation and contract should coverage be bound and/or a policy issued. No coverage is bound or in force until confirmed in writing by our office. The information collected from you is used to underwrite coverage and services. This information will be provided to others. Please read our Privacy policy for further information. By submitting this information to us you agree with the terms of our Privacy policy and generally accepted standards applicable to insurance intermediaries, agents and brokers regarding the submission of data to insurers, underwriters and service providers. I have read the Important Information and understand and agree with the contents thereof.