Current Workmen's Comp Carrier
No Obligation Quote Request Form
Business Legal Name
Business Address
Business Phone No.
Please enter the text shown in the image into the field below.
Protection Code
(New York State Residents Only)
Workers' Compensation Insurance
Applications are subject to Insurance Company approval.

Completion of the above form will secure details, but does not bind or modify coverage.

Policy Renewal Date
Non-Renewal Date
Reason
Federal Employee ID# (FEIN)
Type of Business:
Male Employees
Female Employees
Estimate ANNUAL Gross payroll of all clerical/professional/professional
Staff excluding owners, members or partners and executive officers of a
Professional Corporation:
Professional Corporations (P.C.), "C" or "S" Corporations
(Answer only if one or two executive officers of corporation,
who elect to be included). Executive Officers must own at least one
share of stock to be excluded.

Loss History for past three (3) Years
Policy Year
Carrier
# Claims
Amount Claims Paid
Individual Completing this Form
If applicable, other location(s)
Nature of Business:
Part-Time
Part-Time
Full-Time
Full-Time
Is coverage desired for executive officers of PC?
If Yes, number of officers earning over $94,900/year:

____________ x $94,900 =
YES
NO
(Answer only if more than two executive officers of PC who have to
be included)

Total number of officers/members not included in no. 5 above

____________ x $94,900 =
Total payroll for executive officers/members earning less than $94,900/year
Not included in no. 5 above, 6a 6b (minimum salary is $31,200)
Individual or Partnership, LLP, PLLP, PLLC, or LLC (members):
Is coverage desired for Individual/ owners/partners/members?
YES
NO
(If Yes, answer b & c) (If No, Skip b & c)
Total number of individual owners/partners/members not included in
No. 5 above who earn over $94,900/year

____________ x $94,900 =
Total payroll for Individual owners/partners/members earning less than
$94,900/year. Not included in no. 5 above, 6a 6b (minimum salary is $31,200)
TOTAL ANNUAL PAYROLL

 requestaquote1

faq