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  Workman's Comp Insurance Quote
Full Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Day Telephone:  
Eve Telephone:  
Fax:  
*Please email or fax copies of 3 year loss runs, and any other available information.
 
 Current Insurance Information
Insurance Company Name:
(NOT Insurance Agency/Broker)
Any losses in last 3 years?:  
Number of claims:      Claim amt. pd $:
Premium Amount:      Policy Expiration Date:
MOD Factor:               Policy Number:
Describe the type of Coverage you currently have:
 
 Prior Carrier Information
Insurance Company Name:  
Number of claims:      Claim amt. pd $:
Premium Amount:      Policy Expiration Date:
MOD Factor:               Policy Number:

 

 About Your Business
Number of Full-time employees:
Number of Part-time employees:
Owner's Name:
License Type:       Years in Business:
License Number:       Number of locations:
Annual Gross Sales:         Type of Business:
Please describe your business here:
 
 Owners/Partners/Officers
Name
Date of Birth
Title
Ownership %
 
 Payroll Information
Class Code
Employee Duties
Annual Payroll $
Hourly Wage $
 
 General Information
Do you offer safety programs?   No
Do you offer health benefits to majority of employees? Yes   No
Do you employ any minors (under 18)? Yes   No

Is operation all/part of existing business that was purchased/acquired?

Yes    No

Do you use subcontractors? Yes    No
Use any equipment that bends/shapes/forms? Yes   No
Are athletic teams sponsored? Yes   No
Been a lapse in coverage during past 12 months? Yes    No
Any work above 15 feet? Yes    No
Had a bankruptcy in past 7 years? Yes    No
Are a member of any trade organizations? Yes    No
 
 Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.

We will not distribute information to other parties other than for insurance underwriting purposes.

By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

 

YES! I Agree - By checking this box, you agree to release us from any liability should this information be accidentally viewed by others and you specifically agree that you are permitting any records to be run and reviewed in order to provide you with the best quotation including but not limited to accident loss history, motor vehicle record and credit.

 

   
 

 

 

(p) (828) 258-8030 ∙ (f) (828) 258-8030
(e) tony_johnson_agency@nationwide.com