EmailMe Form - WORKERS' COMPENSATION QUOTE QUESTIONNAIRE

Contact Name
First Last
Business Name
Business Location

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone Number
### - ### - ####
Fax Number
### - ### - ####
Email
BUSINESS INFORMATION
Type of Business
Federal Employer's ID No.:
Detailed Description of Operations
Number of Locations
OWner or Employee Business Travel
Outside Texas
Outside US
If so, note in remarks below how much annually
Number of Owners/Partners
Year Business Started Under Current Ownership
Years Experience Owner has in this Field
Number of Full Time Employees
Number of Part Time Employees
Estimated Annual Payroll
CURRENT INSURANCE INFORMATION
Current Insurance Carrier
Policy Expriation
Losses the Past 3 Years
Yes
No
Loss History OR Provide Currently Valued Loss Runs
List ALL losses for past 3 years: Date, Description, Amount
Required Limits Over 100/500/100? If so, Limits Needed
Experience Mod (if any, per policy)
EMPLOYEE & OWNER CLASSIFICATION INFORMATION
Employee Type - 1
Job Description, Class Code, Annual Payroll Estimate
Employee Type - 2
Job Description, Class Code, Annual Payroll Estimate
Employee Type - 3
Job Description, Class Code, Annual Payroll Estimate
List ALL Owners/Partners/Officers
Include Titles and Class Code
Exclude Owners/Partners/Officers from Coverage?
Yes
No
If yes to Include, Provide Owner Annual Salary
Remarks or Additional Information
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