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WORKER'S COMPENSATION INSURANCE REQUEST FOR QUOTATION

Name of Organization:
Mailing Address:
City ST ZIP
Phone Fax
Email Website
Contact Name
Contact Title
What is the entity's legal structure? Date Organized
Federal ER's ID Number (FEIN)
Description of Operations
Current Carrier Expiration Date
Premium ER's Liability Limits
Does your organization have a safetly committee?
Loss History past 3 years (hard copy of loss runs required prior to binding coverage)
Current NCCI Experience Modification Factor

 

Please indicate the applicable Class Codes, State and Estimated Annual Payroll that appear on your current Workers' Compensation Policy.
Class Codes State Payroll
Code1
Code2
Code3
Code4

Disclaimer:  This information will be used to develop a proposal for Workers' Compensation Insurance.  Additional information may be required on various underwriting guidelines.  By providing us this information, it in no way binds Workers' Compensation coverage for the applicant.