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Workers Compensation Quote Form

 
Workers' Compensation Insurance Quote
We would like to provide you with a free, no-obligation Workers' Compensation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Business:
Contact Name:
Address:
City:   State:   Zip:
Practice Phone:   Fax:
Contact Email Address:

 

Current Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
NCCI Number:
NCCI Experience Modification Number:
What type of coverages do you currently have:
Bond
Commercial Auto
Commercial Liability
Commercial Property		 Commercial Umbrella
Directors & Officers Liability
Disability
Group Health		 Group Life
Professional Liability
Other  

 

About Your Practice
# of full-time
employees
# of part-time
employees
How long
in practice
How many
locations
Estimated Annual
Payroll
years
$
Please give a brief description of your practice (below):
Additional Practice Information
Do you have any losses in the past 3 years?: Yes No
Do you have Independent Contractors?: Yes No
If yes, how many?:
Do paychecks reflect the above name?: Yes No
If no, please provide details:
Federal Tax TD:
Type: Corporation Partnership
Individual    Other
Average hourly wage for non-physician employees: $ / hour
List all Officers/Partners
Name: Title: % Ownership: Excluded/Included:
What is the practice specialty?
Off premise operations: Yes No

 

Employee Information
Employee#
Classification code
Estimate Yearly Payroll
1
2
3
4
5
Please list additional employees in the "Additional Comments" section below


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

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