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*indicates required fields *Company *Contact Person *E-mail *Street address *City County State *Zip Code Home Phone Work Phone FAX FEIN   Address City County State Zip Code   Type of Company Individual Partnership Corporation S-Corporation Other   If Individual, please indicate: Owner's Name     Social Security # Spouse's Name   Social Security # Years in Business License Number    Type of License NCCI Number Other Rating Bureau ID Number Total Gross Receipts Employee's Payroll Nature of Business Operations   Location Class Code Categories, Duties # of Employees Estimated Annual Remuneration   Person Name Date of Birth (i.e., 01-01-65) Title Relationship Ownership % Duties Incl/Excl 1 2 3 4 5   Year Carrier Policy Number Annual Premium MOD # of Claims Amount Paid *Must provide 4 years of loss to run quote   Yes No 1. Does the applicant own, operate or lease Aircraft/Warcraft? Yes No 2. Do/have past, present or discontinued operations involve(d) storing, treating, discarging, applying, disposing, or transporting of hazardous material? (e.g.landfills,wastes,fuel tanks,etc) Yes No 3.  Any work performed underground or above 15 feet? Yes No 4.  Any work performed on barges, vessels, docks, bridge over water? Yes No 5.  Is applicant engaged in any other type of business? Yes No 6.  Are sub-contractors used? Yes No 7.  Any work sublet without certificate of Insurance? Yes No  8.  Is a formal safety program in operation? Yes No 9.  Any group transportation provided? Yes No 10.  Any employees under 16 or over 60 years of age? Yes No 11.  Any part time or seasonal employees? Yes No 12.  Is there any volunteer or donated labor? Yes No 13.  Any employees with physical handicaps? Yes No 14.  Do employees travel out of state? Yes No 15.  Are athletic teams sponsored? Yes No 16.  Are physicals required after offers of employment are made? Yes No 17.  Any other insurance with this insurer? Yes No 18.  Any prior coverage declined/cancelled/non-renewed (last 3 years)? Yes No 19.  Are employee health plans provided? Yes No 20.  Is there a labor interchange with any other business/subsidiary? Yes No 21.  Do you lease employees to or from other employers? Yes No 22.  Do any employees predominantly work at home?     Inspection Accounting Records Claims Info   How would you like to receive your free Worker's Compensation quote? U.S.Postal E-mail Fax