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Workers Compensation Quote

PLEASE FILL OUT THE FORM BELOW AND SUBMIT FOR A FREE NO-OBLIGATION QUOTE FOR YOUR WORKERS COMPENSATION INSURANCE NEEDS:

NORTH CAROLINA RESIDENTS ONLY.

* = Mandatory

Name: *

Title:

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Organization:

Home Phone: *

Work Phone:

Fax:

Email: *

URL:

General Information

Years In Business: *

SIC Code:

Federal Employer ID Number:

NCCI ID Number:

Type of Individual
Business: * Partnership
Corporation
Subchapter 'S' Corp
Limited Corp
Other

Nature of Business/Description of Operations (Give comments and descriptions of business, operations, and products: manufacturing--raw materials, processes, product, equipment, contractor--type of work, sub contracts, mercantile--merchandise, customers, deliveries, service--type, location, farm--acreage, animals, machinary, sub-contracts): *

Prior Carrier Information/Loss History

Year:

Company:

Policy #:

Annual Premium:

MOD:

# Claims:

Amount Paid:

Reserve:

Remarks:

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Company:

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# Claims:

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Year:

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MOD:

# Claims:

Amount Paid:

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Annual Premium:

MOD:

# Claims:

Amount Paid:

Reserve:

Remarks:

Year:

Company:

Policy #:

Annual Premium:

MOD:

# Claims:

Amount Paid:

Reserve:

Remarks:

Individuals Included/Excluded

Name:

Date of Birth:

Title / Relationship:

Ownership %:

Duties:

Inc/Exc:

Class Code:

Remuneration:

Name:

Date of Birth:

Title / Relationship:

Ownership %:

Duties:

Inc/Exc:

Class Code:

Remuneration:

Name:

Date of Birth:

Title / Relationship:

Ownership %:

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Inc/Exc:

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Remuneration:

Name:

Date of Birth:

Title / Relationship:

Ownership %:

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Inc/Exc:

Class Code:

Remuneration:

Name:

Date of Birth:

Title / Relationship:

Ownership %:

Duties:

Inc/Exc:

Class Code:

Remuneration:

Rating Information

State:

LOC:

Class Code:

Company Use:

Categories, Duties, Classifications:

# Employees Full Time:

State:

Estimated Annual Remuneration:

Rate:

Estimated Annual Premium:

State:

LOC:

Class Code:

Company Use:

Categories, Duties, Classifications:

# Employees Full Time:

State:

Estimated Annual Remuneration:

Rate:

Estimated Annual Premium:

State:

LOC:

Class Code:

Company Use:

Categories, Duties, Classifications:

# Employees Full Time:

State:

Estimated Annual Remuneration:

Rate:

Estimated Annual Premium:

State:

LOC:

Class Code:

Company Use:

Categories, Duties, Classifications:

# Employees Full Time:

State:

Estimated Annual Remuneration:

Rate:

Estimated Annual Premium:

Specify Additional Coverages / Endorsements (If needed):

Additional space for additional classifications, information, etc (If needed):

How would you like to receive your quote:

Workers Compensation Quote

General Information

Please explain all "Yes" answers

Prior Carrier Information/Loss History

Individuals Included/Excluded

Rating Information