Worker's
Compensation Quote Form
Please
fill out as much information as possible. If you have any questions
about this form or filing a claim, please contact
us.
|
| BUSINESS
INFORMATION |
| Name
of Business: |
|
| Contact
person: |
|
| All
locations of business: |
|
| Type
of business: |
|
| Preferred
method of contact: |
|
|
E-mail: |
|
|
Telephone: |
|
|
Fax: |
|
| Tax
Identification Number: |
|
| COVERAGES
REQUESTED |
| Employers
Liability: |
|
Each Accident: |
|
|
Disease - Policy Limit: |
|
|
Disease - Each Employee: |
|
| NAME
OF EACH EMPLOYEE, JOB DESCRIPTION AND ANNUAL PAYROLL |
| Please
list all employees. Include name, job description and annual
payroll for each person. |
|
| NAME
OF ALL PARTNERS OR OFFICERS |
| Please
list all partners or officers. Include name, title, % of
ownership and duties for each person. Also indicate if they
should be included or excluded. |
|
| CLAIMS
HISTORY FOR 3 YEARS |
| Please
list all claims within the last three years. |
|
| OTHER
INFORMATION |
| Do
you have any overseas locations?: |
|
| If
so, please provide their addresses. |
|
| What
percentage of work is performed by sub-contractors? |
|
| Who
is your current insurance carrier? |
|
| How
long have you been insured with this carrier? |
|
| |
|
|
|
|
| Submitting an insurance quotation request
to Alexander & Strunk Insurance does not constitute a binding confirmation
of new or altered insurance coverage. Verbal and/or written confirmation
must be obtained from Alexander & Strunk Insurance to confirm binding or altering
coverage. |
