Workers Compensation Insurance Quote Form in Rochelle, Illinois


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Workers Compensation Insurance Quote Form
	First & Last Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:
	Current Insurance Information
Insurance Company Name:
Any losses in last 3 years?:
# of claims:		Claim amt. pd $:
Premium Amount:		Policy Exp. Date:
MOD Factor:		Policy #:
Describe the type of Coverage you currently have:
	Prior Carrier Info
Insurance Company Name:
# of claims:		Claim amt. pd $:
Premium Amount:		How many years with:
MOD Factor:		Policy #:
	About Your Business
# of Full-time:		# of Part-time:
Owner's Name:		Fed Tax ID:
License Type:		Yrs in Business:
License #:		# of locations:
Annual Gross Sales:		Square Footage:
Est payroll / mo.:		Type of Business:
Please describe your business here:
	Owners / Partner / Officers
Name	Date of Birth	Title	Ownership %



	Payroll Information
Class Codes	Employee Duties	Annual Payroll $	Hourly Wage $




	General Information
Do you offer safety programs?
Do offer health benefits to majority of employees?
Do employ any minors (under 18)?
Operation all/part of exist. business purch/acq?
Do you use subcontractors?
Use any equipment that bends/shapes/forms?
Are athletic teams sponsored?
Been a lapse in coverage during past 12 months?
Any work above 15 feet?
Had a bankruptcy in past 7 years?
Are a member of any trade organizations?
Additional Information: Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.

Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentially viewed by unauthorized others. We will only use this information for insurance quoting purposes and not distribute to other parties.

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