Workers Compensation

The following questions concern the type of business insurance coverage you are requesting . Please answer them as accurately as possible.
1) Description of the business:

2) What type of entity is your company?

3) Please indicate the state in which your business is located:

4) What is the date of incorporation?

MM/YY

5) Please indicate your total number of full-time employees:
(If Sole Proprietor enter 1)

6) Please indicate your total number of part-time employees:
(If none please enter 0)

7) Please indicate your total annual revenue:

8) Please indicate your total annual payroll:

9) Do you currently have insurance?

Yes No

10) If you are currently insured, please select your current insurance carrier:

11) If your provider is not listed above, please provide the company name here:

12) How many years have you had coverage with this company?

13) How many years have you had continuous coverage (With no lapse)?

14) If you do not have coverage please indicate when you would like a policy to go into effect:

Please complete the questionnaire, and we'll begin our search for the most suitable insurance policy for your business.
15) Best Time To Contact:
16) Additional Comments: Please provide any additional information you feel is pertinent to the insurance coverage you need.