Workers Compensation (Comp) Quote Form

 

Company Name :

D/B/A :

 

Mailing Address

Address :

City :  State:    Zip:

 

Physical Address

Address :

City :  State:    Zip:

 

Contact Name: 

Phone #() -                                     Check Here if you would like a call rather than completing the form online

Alternate Phone #() -

Fax #: () -

Email:

Best Time to Contact and Where (Normal Business Hours)

Federal Employer Identification Number: -          

Type of Entity:

Description of Operations and Radius of Travel:

Present Workers Compensation Carrier:

Years in Operation:

Workers Compensation Claims:

Do you have a Written Formal Safety Program in effect:               

Do You have a Drug-free Workplace program in effect:                

 

 

 

 Owners/ Officers                                                                                                                                   

   Name                                                  DOB             Social Security             Title            Salary           Inc /  Exc    % Owned

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Employees

 

Total # of Employees:  

Total # of Part-time Employees:

Do you have any individual(s) that are 1099 for wages:

 

 

Departments / Classes of Employees   (If you do not know your Class Code, please leave blank and complete the description in detail.)

 

State:  Code:  Annual Payroll for this Class $

# of employees in this class   

Description of Duties for this class: 

 

 

State:  Code:  Annual Payroll for this Class $

# of employees in this class   

Description of Duties for this class: 

 

 

State:  Code:  Annual Payroll for this Class $

# of employees in this class   

Description of Duties for this class: 

 

 

State:  Code:  Annual Payroll for this Class $

# of employees in this class   

Description of Duties for this class: 

 

 

State:  Code:  Annual Payroll for this Class $

# of employees in this class   

Description of Duties for this class: 

 

 

State:  Code:  Annual Payroll for this Class $

# of employees in this class   

Description of Duties for this class: 

 

 

 

Employees   (If you have a current list with this information, just attach it)

 

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If you have more employees than 30, please fax a list of your employees to us at 800-801-8859 or email a list to webmaster@floridadirect.com. If emailed, please put the name of your company in the subject line so we may match it to your quote. Call us if you should have questions at 800-763-6118. Thank you!

 

 

Would like for us to also give you a quote for Health Insurance :

 

 

Applicant Questions (Please circle yes or no. If “yes” to any question, please explain in remarks.)

 

 

DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT?

   

 

DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTINGOF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)\

 

ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?

 

 

 ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?

 

IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?

 

ARE SUB-CONTRACTORS AND/OR INDEPENDENT CONTRACTORS USED?

 

ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.?

 

IS A FORMAL SAFETY PROGRAM IN OPERATION?

 

ANY GROUP TRANSPORTATION PROVIDED?

 

ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?

 

ANY PART TIME OR SEASONAL EMPLOYEES?

 

IS THERE ANY VOLUNTEER OR DONATED LABOR?

 

ANY EMPLOYEES WITH PHYSICAL HANDICAPS?

 

DO EMPLOYEES TRAVEL OUT OF STATE?

 

ARE ATHLETIC TEAMS SPONSORED?

 

ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?  

 

ANY OTHER INSURANCE WITH THIS INSURER?

 

ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED (Last 3 years)?

 

ARE EMPLOYEE HEALTH PLANS PROVIDED?

    If yes, with whom:  Expiration Date: 

 

IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?

 

DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

 

DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?

 

WHAT ARE YOUR ESTIMATED ANNUAL REVENUES? $

 

IS THERE ANY CURRENT OR ANTICIPATED DEBT FOR UNPAID PREMIUMS  OWED TO ANY PREVIOUS WORKERS’ COMPENSATION PROVIDER?

 

Remarks: