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Workers Comp Quote Request Sheet
Primary Contact Information
First Name
*
Last Name
*
Email
*
Phone Number
*
Mailing Address
Street Address
City
State
ZIP
Business Information
Business Name
*
(entity name)
Doing Business As (DBA)
(if applicable):
Business Entity
*
Individual
Partnership
Corporation
LLC
Joint Venture
Association
Other
Date Business Started
*
Month
/
Day
/
Year
FEIN
*
Location Street Address
*
City
*
State
*
ZIP
*
Current Policy Effective Date - OR - Date New Coverage Should Begin
*
Month
/
Day
/
Year
Annual Receipts
*
Individuals Included/Excluded
Individual 1
Name
Title/Relationship
Ownership %
Included/Excluded
Included
Excluded
Class Code
Payroll
Duties
Employee Classification
Classification 1
Class Code
*
Full Time Employees
*
Part Time Employees
*
Categories, Duties, Classifications
*
Estimated Annual Payroll
*
Classification 2
Class Code
Full Time Employees
Part Time Employees
Categories, Duties, Classifications
Estimated Annual Payroll
Classification 3
WC Class Code 3
Full Time Employees
Part Time Employees
Categories, Duties, Classifications
Estimated Annual Payroll
Current Carrier Information
Current Carrier
*
(Please put "None" if no current policy)
Annual Premium
*
Please attach Loss Runs if available
Nature of Business
Nature of Business
*
Give description of business, operations, and products:
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