Workers Compensation Insurance
|
Contact Information
|
|
Name *
|
|
|
Date of birth
|
MM
|
/
|
DD
|
/
|
YYYY
|
|
|
Gender
|
Male
Female
|
|
Phone *
|
|
|
Fax *
|
|
|
Email *
|
|
|
Marital Status
|
|
|
Best day to contact
|
|
|
Best time to contact
|
|
Business Information
|
|
Business Name
|
|
|
Physical Location
|
|
|
Year Business Established
|
|
|
Nature of Business
|
|
|
Describe Business Operation
|
|
|
Premises Square Footage
|
|
|
Payroll (not including owners)
|
|
|
Number of Employees
|
|
|
Do you have more than one location?
|
yes
no
|
|
Do you use Independent or Sub-Contractors?
|
yes
no
|
Prior Carrier Information
|
|
Insurance Company Name
|
|
|
Length of Coverage
|
|
|
# of claims
|
|
|
Claim amt. pd $
|
|
|
MOD Factor
|
|
|
Policy #
|
|
Additional Information
|
|
Do you offer safety programs?
|
yes
no
|
|
Do offer health benefits to majority of employees?
|
yes
no
|
|
Do employ any minors (under 18)?
|
yes
no
|
|
Operation all/part of exist. business purch/acq?
|
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
|
|
Additional Comments
|
|
|
|
|
|
