WORKERS COMPENSATION QUOTE FORM (Acord 130)

Your First Name: * Your Last Name: *
Email Address: * What is your corporation's name:
What is your federal ID number: Phone #:
Fax #: What is your location address:
City: State: Zip Code:
Number of employees: Full time:
Part time: Number of officers:
Name of Officers: Title % of share
1.
2.
3.
4.
Employee's payroll: Full time:
Part time: Officer's payroll:
Who is your current Insurance company: Expiration date:
Current premium: $ Have you reported any claims in the past 3 years?
If Yes, please describe loss:
 NOTES