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Workmans Compensation Questionnaire

Please fill out the form below for your free Workmans Compensation insurance quote. Be sure to fill out the form entirely.

Insured Name:
Email Address:
Policy #(if renewal):		Effective Date:

Detailed description of operations and employees duties:

Payroll for the past three years:

# of employees:

Increasing: Yes	No
Decreasing: Yes	No

# of part-time employees:
# of full-time employees:

Average wage for employees in main classification:

Ownership? Yes	No
Active in Management? Yes	No
Absentee? Yes	No

Percent of Off Premises Operations:
*not applicable to contracting risks.

Vehicle exposure: Yes	No	MVR's checked: Yes	No
Does insured deliver: Yes	No
Delivery radius: less than 50	51-100	101-500
Vehicle owned: Yes	No	Taken home: Yes	No
Vehicle Inspection Program: Yes	No

Please provide name(s) of any affiliated trade of idustry associations:
Have you had continuous insurance for the past three years? Yes	No

What is your experience modification (if any)?

Date:

Which agent (if any) referred you to this website?

Additional Comments:

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