Transcription of WORKERS' COMPENSATION QUOTE FACT SHEET
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WORKERS' COMPENSATION QUOTE FACT SHEET
WORKERS' COMPENSATION QUOTE fact SHEET Company Name:_____ Trade Name ( DBA): _____ Business Ownership Legal Name: _____ Phone #_____ Fax # _____ Number of Locations: _____ Email _____ Website: _____ Company Address:_____ City: _____ State: _____ Zip code: _____ Mailing/Billing Address:_____ City: _____ State: _____ Zipcode: _____ Contact Name & Title: _____Federal Employer ID #: _____ State Employer ID #:_____ Years in Business: _____ Date Business Began: ___/___/_____ Legal Entity: Individual____ Husband & Wife _____ Partnership _____ Corporation _____ S Corp _____ Limited Corp___Other_____ Group Health Carrier: _____ Current W/C Carrier: _____Expiration Date: ___/____/___ Requested Effective Date:__/__/____ ======================================== ======================================= Rating Information (Refer to your current policy): Class Code Job Description # Full-time Employees # Part-time Employees Estimated Payroll Rate Estimated Annual Premium
WORKERS' COMPENSATION QUOTE FACT SHEET Company Name:_____ Trade Name (i.e. DBA): _____ Business Ownership—Legal Name: _____
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