Request For Proposal

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Request for Proposal

Workers' Compensation Form

*Please Provide as much information as possible to assure the most accurate quotes. Leave blank if you are not sure of an answer.
3 years of loss runs
If you don't have loss runs and have no had any injuries, we need a letter, on your letterhead, stating there have been no losses.
Experience Modifier
General Information
Name of Business
Name of Owners/Officers
Contact Name
Contact Phone & Fax	Phone Fax
Contact E-mail
Address
City		State	Zip
Current/Previous Insurance Information
Current insurance company		Annual Premium
Policy Period	Effective Date Expiration Date
Work Comp Modifier (if Known)
Will Owners be Included or Excluded- Please Explain
Additional Owner Information
Social Security Numbers		Date of Births
Percentage of Ownership
Any Other Carriers(last 3 years)	No Yes If yes, please list name and estimated premium

Any Insurance Claims Filed(last 3 years)	No Yes If yes, please give following data

Date of Claims		Amount of Claims
Description		Cost of Claims
Payroll & Class Code Information
Class Code (or) Job Description	# FT Employees	# PT Employees	Estimated Payroll per Class Code





Other Information
List any additional Locations:
Do You Require Coverage Above Mandatory Limits	No Yes If yes, please describe required limits:
Do You Work Outside of Your State	No Yes
Do you use a payroll company
If so, what company
Additional Comments & Information
Please tell us anything else you think might be helpful to know in order to provide accurate insurance quotes: