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Workers' Compensation

Please fill out the form below. You may also fill out our short form by clicking here.

General Information
How did you hear about us? *
BIA Chamber of Commerce
Current Client Email
Google Yahoo
Mailer Yellow Pages
Referral: Website:
Other:  
Named Insured:
Contractor's License #:
Owner's Name:
Contact's Name:
Phone: *
 Fax:
Cell:
Email Address: *
 Preferred method of contact: *
Phone Fax Email Mail
Address Information
Mailing Address
Street: *
City: *
State: *
Zip: *
 
Premise Address
Street:
City:
State:
Zip:
Business Entity: *
Sole Proprietorship Partnership Corporation LLC Other:
Business Information
Bus Lic #: FEIN: SSN:
Hours Operation: Out of State Travel: Yes No
Years in Business: Years of Experience:
Ownership Information
Full Name Include or Exclude DOB % of
Ownership		 Official Title Active in the Field?
Inc Exc Yes No
Inc Exc Yes No
Inc Exc Yes No
Inc Exc Yes No
Operations Performed By Employees
Describe, in detail, the operations performed by you and your employees:
Type of Work Details
Max Height in Feet:   Max Height Type of Work:
Scaffolding (Your Own):   Scaffolding (Lease/Rented)   Ladder   Scissor Lift
Max Depth in Feet:   Type of Work:
Average Annual Gross Receipts:
Average Annual Subcontractor Costs:
Type of Work Details
The following is the basis of the quote, and must be provided.
Class Code or Desc
(Please be as complete as possible)		 Expected
Annual Payroll		 Average
Hourly Wage		 # of
Fulltimers		 # of
Partimers
Previous Coverage Details
Have you had prior coverage during the last five years? Yes No
**Loss run reports will be required
Have there been any losses or claims in the last five years? Yes No
Is your coverage currently in force? Yes No    Expiration date:
Carrier:
Benefits
Do you offer any of the following benefits?
Group Health (Would you like a quote? Yes No) Paid Sick Leave
Paid Vacation Retirement Plan/Pension Plan Other
You use a specific clinic, physician, or emergency room?
Hiring Practices
Do you use any of the following hiring practices?
Employment Applications Reference Checks Motor Vehicle Reports
Volunteer Labor Temporary Labor Drug/Substance Abuse Testing
Pre/Post Employment Physical Back Testing Other:
Saftey Programs
Do you use any of the following hiring practices?
Injury & Illness Prevention Plan Safety Incentive Plan Employee Orientation
Formal Written Accident Report Safety training/meetings Personal Protection Equipment
Post accident drug testing Other:
Additional Comments
Comments:
Legal Terms
You MUST agree to our terms and conditions to submit this request by doing both of the following:
This is not an application, it is only a preliminary info sheet for a quote. Additional information may be required.
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Print your Initials: *
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