Encompass Insurance Consultants - Workers Comp Quote

Workers Comp Quote

Workers Compensation Insurance Quote Form
Contact 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 long with current:
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)?
Is operation all/part of existing business that was purchased/acquired?
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 Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form We will only use information provided to assist in obtaining appropriate insurance quotes and coverage. We will not distribute information to other parties other than for insurance underwriting purposes. By checking the box below you agree to release us from any liability should this information be accidentally viewed by others. YES! I Agree