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Worker's Comp Insurance Quote
(
Texas residents only.)
GENERAL INFORMATION
NAME OF BUSINESS
CONTACT NAME
ADDRESS
CITY
STATE
ZIP
BUSINESS PHONE
FAX PHONE
BEST TIME TO CALL
AM
PM
E-MAIL ADDRESS
LOCATION ADDRESS
Type "same" if same as above. List additional locations in the "additional information" box at the end of the form.
CITY
STATE
ZIP
PLEASE DESCRIBE YOUR BUSINESS, PRODUCT AND/OR SERVICE
PLEASE TELL US ABOUT YOUR BUSINESS
# FULL-TIME
EMPLOYEES
# PART-TIME
EMPLOYEES
NUMBER OF
YEARS IN BUSINESS
PROJECTED GROSS
ANNUAL RECEIPTS
PROJECTED TOTAL
ANNUAL PAYROLL
PLEASE PROVIDE INFORMATION ON YOUR INSURANCE CARRIER
INSURANCE CARRIER
POLICY NUMBER
WC PREMIUM
YOUR POLICY
RENEWAL DATE
HOW MANY YEARS WITH
CURENT INSURANCE CARRIER?
(MM/DD/YY)
If prior policy has been with a different carrier than the current, please list in the additional comments section at the end of the form.
QUOTE INFORMATION
EMPLOYERS LIABILITY LIMITS
EXPERIENCE MOD
Choose
$500/$500/$500
$1,000/$1,000/$1,000
(If not applicable, type N/A)
WORK COMP CLASS CODE(S) (By job description)
ANNUAL PAYROLL
PLEASE DESCRIBE
WORK COMP CLASS CODE(S) (By job description)
ANNUAL PAYROLL
PLEASE DESCRIBE
WORK COMP CLASS CODE(S) (By job description)
ANNUAL PAYROLL
PLEASE DESCRIBE
WORK COMP CLASS CODE(S) (By job description)
ANNUAL PAYROLL
PLEASE DESCRIBE
OWNERS
Choose
Included
Excluded
(If included, please make sure payroll & class codes are provided)
PLEASE LIST ALL LOSSES/CLAIMS IN THE PAST 3 YEARS. IF NONE, PLEASE TYPE NONE IN THE FIELD.
ADDITIONAL INFORMATION
PLEASE LIST ANY ADDITIONAL INFORMATION PERTINENT TO FORMULATING A QUOTE.
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