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Workers' Compensation Application

First Name

Contact Name

Street Address

City

State

Zip

Telphone

Fax

E-Mail

Underwriting Information

1. What is the nature of your business?

2. Is the business a

Corporation,
Partnership or
Sole Proprietorship?

3. How many owners are there?

4. How many employees are there (including owners)?

5. What is the gross annual payroll amount?

Clerical: $

Architect/Engineers: $

Executive Officers: $

Describe Others:

6. What is the total annual gross revenue or sales?

7. What is the Federal Employer ID Number?

Coverage Information

8. What is your current insurance company?

9. What is your expiration date?

Are there any questions, comments or additional coverage required?

All information provided is confidential and will be used soley to obtain an indication for coverage.
Coverage cannot be bound from this information sheet.