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Workers' Compensation Quote
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Indicates required field
Future Effective Date
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Referred By
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Contact Information
Name (Last Name, First Name)
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ex) Kim, Justin; Nguyen, James
Mailing Address (Street, City, State, and Zip Code)
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Phone Numer
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Email
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Officer/Owner Information
Name (Last Name, First Name)
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ex) Kim, Justin; Nguyen, James
Name (Last Name, First Name)
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ex) Kim, Justin; Nguyen, James
Title
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Title
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Date of Birth
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Date of Birth
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Social Security Number (SSN)
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Social Security Number (SSN)
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Choose One
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Include
Exclude
Choose One
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Include
Exclude
Business Information
Legal Name of Business
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Legal Entity
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N/A
Individual
Partnership
Corporation
Other
If other please specify:
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Federal Employer Identification Number (FEIN)
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Business Address (Street, City, State, and Zip Code)
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Business Email
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Business Phone Number
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Business Fax Number
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General Information
Description of Operation/Occupancy
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Years in Business
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Loss History (Any Loss)
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Loss Run Obtained:
Maximum number of EE at one time?
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Offer delivery?
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Yes
No
Are there any employee under 16 or over 60?
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Yes
No
Does the applicant use forklifts or heavy equipments?
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Yes
No
Store opens past 11pm?
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Yes
No
Payroll Breakdown:
Total Annual Payroll ($)
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Number of Full-Time Employees
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Number of Part-Time Employees
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Code:
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ex) 8810
Code:
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ex) 8810
Code:
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ex) 8810
Code:
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ex) 8810
Code:
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ex) 8810
Job Description:
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ex) clerical, manager, cashier
Job Description:
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ex) clerical, manager, cashier
Job Description:
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ex) clerical, manager, cashier
Job Description:
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ex) clerical, manager, cashier
Job Description:
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ex) clerical, manager, cashier
Payroll:
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ex) $100.00
Payroll:
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ex) $100.00
Payroll:
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ex) $100.00
Payroll:
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ex) $100.00
Payroll
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ex) $100.00
For contractors, any 1099-misc payment?
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Yes
No
If so, $
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Insured
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Uninsured
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Current/Prior Insurance Information
Please send a copy of your policy declaration page if possible.
Insurance Carrier
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Year
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Term of Agreement
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I, hereby, declare that the information provided above is true and authorize C&N Insurance Agency, Inc to use them for workers' compensation enrollment and customer service purposes only.
Comment
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