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Quick Workers Compensation Quote

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Policy Start

When would you like this policy to start *

Is your policy in cancelation status or has it recently been cancelles *

No

Yes

What is the actual date it will cancel or was canceled *

Contact Details

Name *

Work Phone *

Cell Phone *

Fax (optional)

Email *

Contact me via *

Email

Phone

Company *

Company URL (if available) *

Current Policy Available

Is your policy available *

Yes

No

Please upload a copy of your policy or fax 720-358-4737 *

Previous Carrier Information

Current insurance carrier name *

What is the policy period *

What is the policy premium *

Have you been with your current carrier 24 months or longer *

Yes

No

List claims & amounts paid (if none, type NONE) *

Most previous carrier name *

What is the policy period *

What is the policy premium *

List claims & amounts paid (if none, type NONE)

Business Information

Name of business *

Your title/position *

Standard industry code *

What is your main business activity *

How long has the business been operating *

Is your business based in your home *

No

Yes

Number of full time employees *

Number of part time employees *

Is there any volunteer or donated labor *

No

Yes

Gross annual payroll *

Gross annual revenue *

What will your revenue be for the next fiscal year *

Additional wage codes/wages (if any)

Number of owners, directors, officers *

Do you own more than 50% of another businessother than the one described *

No

Yes

Please provide the full name of the other business *

Is this other business insured elsewhere *

Yes

No

Have you included exposures associated with the other business with the submission *

Yes

No

Is the other business listed as a named insured in this submission *

Yes

No

Please describe the operations of the other business *

Do you want to include owners, directors, and officers in this policy *

Yes

No

Are you closed more than four consecutive weeks during the year (seasonal operations) *

Yes

No

Does any of your business involve subcontracting work to others *

Yes

No

What percentage of your profressional services are contracted out *

Do you require your subcontractors to carry liability insurance *

Yes

No

Building Information

Any work performed underground or above 15 feet *

Yes

No

Is a written safety program in operation *

Yes

No

Any group transportatioon provided *

Yes

No

Do employees predominatley work from home *

Yes

No

Verification *

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