WC Quote
Fields marked (
*
) are mandatory.
Name of Applicant
*
Mailing Address
*
Proposed Effective Date
*
F.E.I.N. or SSN
*
Phone
*
Fax
Email
*
Website address
General Business Information
Inspection Contact Name
Inspection Contact Phone
Accounting Contact Name
Accounting Contact Phone
Number of Years in Business
*
Date Business Started
Description of Business
Current and Prior Policy Information
Claims/Loss History(5 Years)
Prior Carrier Information (last 5 years)
Carrier Name and Year #1
Carrier Name and Year #2
Carrier Name and Year #3
Carrier Name and Year #4
Carrier Name and Year #5
Owner/Officers
Officer 1 Name
Officer 1 Duties
Officer 1 Include/Exclude for Coverage
Officer 1 DOB
Officer 2 Name
Officer 2 Duties
Officer 2 Include/Exclude for Coverage
Officer 2 DOB
Officer 3 Name
Officer 3 Duties
Officer 3 Include/Exclude for Coverage
Officer 3 DOB