* Agency Name:
* Contact Name:
* Agency Phone:  
* Agency Fax:
Agency Email:

Owner's Information
* Business Type: Individual Partnership Corporation

Owner/Officer(s) Names:
#1 #2
#3 #4

Percentage of Ownership:  
#1 #2 #3 #4

Included/Excluded:
#1 Included Excluded      #2 Included Excluded
#3 Included Excluded      #4 Included Excluded


Policy Information
* Business Name:
* Federal ID #:
* Years in Business:
* Telephone Number:

Proposed Effective Date:

Employer's Liability:
  Each Accident
  Disease-Policy Limit
  Disease-Each Employee

* Location(s): Street, City, County, State, Zip Code


* of Work Performed

Rating Information
* Class Code: #1
State: Loc.:
Type of Work Performed:
Avg. Hourly Pay of Full-Time Employees:
Number of Full-Time Employees:
Number of Part-Time Employees:
Est. Annual Payroll:

Rating Information
* Class Code: #2
State: Loc.:
Type of Work Performed:
Avg. Hourly Pay of Full-Time Employees:
Number of Full-Time Employees:
Number of Part-Time Employees:
Est. Annual Payroll:

Rating Information
* Class Code: #3
State: Loc.:
Type of Work Performed:
Avg. Hourly Pay of Full-Time Employees:
Number of Full-Time Employees:
Number of Part-Time Employees:
Est. Annual Payroll:

Rating Information
* Class Code: #4
State: Loc.:
Type of Work Performed:
Avg. Hourly Pay of Full-Time Employees:
Number of Full-Time Employees:
Number of Part-Time Employees:
Est. Annual Payroll:

* Has there been a cancellation/lapse in coverage due to
    non-payment of premium in the past 18 months? Yes No

Are employee health plans provided? Yes No

* Current year experience modification:
* Previous year experience modification:
* Any tax liens or bankruptcy within last 5 years? Yes No

* Does company have work comp coverage currently? Yes No
    If Yes, how many years? Expiration Date:

* Has company had any claims in the past 3 years? Yes No

***PLEASE FORWARD 3 YEARS LOSS HISTORY REPORTS***
Even if company has no losses, loss reports or a no loss letter on company letterhead, are still required for quoting purposes and potential additional discounts.

The Commercial Department targets 48 hours for turnaround of quotes on fully completed submissions, unless the risk is referred to the company based on the class of business. If referred, you will be advised by the Underwriter.