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Workers Compensation Insurance Quote Request
Contact Name Primary Owner's Name
Business Legal Name Business DBA
Address City
State Zip
Phone Ext
Fax Email

Underwriting
Nature of Your Business Federal Employer ID
Current WC Insurance Carrier Multi-State Employer
Renewal Date Medical Insurance Provided

Payroll
Annual Gross Payroll Number of Owners
Total Payroll of Owners Number of Employees
Total Payroll of Employees Exclude Owners

Class Code WC Rate Annual Payroll
Employee Group 1
Employee Group 2
Employee Group 3
Employee Group 4
Employee Group 5

Business Background
Years of Experience Years Operating This Business
Business License City Business License Type
Business License Number
Who does your payroll?

Risks
Are you open 24 hours a day? Do you deep fry foods? Do you fill propane tanks?
Please provide a "loss value run" report from your current WC carrier.
Other comments regarding your business which may effect WC coverage.

Claims and Losses For Last Five Years
Description Amount($)
                 

 

Workers' Comp quote request sheet

For more information on Time2Pay™ payroll and human resources services, call Accuchex toll free at 1-877-422-2824 or get started now on the Web.

Fill out this form for a quote on Workers' Compensation insurance to meet your needs (items in bold are required).
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