Workers Compensation Quote October 9, 2017by admin Workers Compensation Quote Broker NamePhoneEmail Company InformationCompany NameAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Premises Location Different Than Above?YesNoPremises LocationPremises Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contractors License #Federal ID #Social Security #Does Insured Have Prior Insurance?YesNoPrior Insurance InformationCurrent InsuranceExp. Date of Current Insurance Expiring PremiumHow Many Years Insured?1 Year2 Years3 Years4 Years5+ YearsTarget PremiumAny Gaps in Insurance Coverage in Last 3 Years?YesNoBusiness Operating InformationHow Many Owners/OfficersHow Many Owners/Officers In The FieldHow many field employees FULL TIMEHow many field employees PART TIMEAnnual payroll FIELD EMPLOYEES ONLYClass CodesAdvise Class Codes Annual Employee Payroll for EachClass CodeEmployee Annual PayrollClass CodeEmployee Annual PayrollClass CodeEmployee Annual PayrollClass CodeEmployee Annual PayrollClass CodeEmployee Annual PayrollFollowing 2 Questions Must Equal 100%ResidentialCommercialFollowing 4 Questions Must Total 100%Service/RepairNew ConstructionNon-Structural RemodelingStructural RemodelingAdditional QuestionsBuild new custom homes as a general contractor / developer?YesNoAny losses in the last 4 years?YesNoIf B License, Framing Work %Maximum Exterior Height?Maximum Depth?Description of OperationsAdditional Comments and/or QuestionsFile
