Business Name:
Contact Person:
Address:
City:
State:
  Zip: 
Telephone: (please include area code)
Cell phone: (please include area code)
Fax: (please include area code)
E-Mail:
  (e.g., yourname@somewhere.com)
   

Company Information

Business Type: other:
Federal Tax ID:
If Individual, owner's SSN:
Spouse SSN:
Years in Business:
License #:
License Type:

Owners / Partners / Corporate Officers

How Many Owners/Partners/Corporate Office do you have?

Prior Carriers

How Many Carriers do you have?

Payroll Information

How Many Employees do you have?

General Information:

Do you offer safety incentive programs?

Do you offer health benefits to majority of employees?

Do you employ any minors (under 18)?

Was this operation all or part of an existing business that was purchased or acquired?

Do you use subcontractors?

Do you use any equipment that bends, shapes, or forms?

Are athletic teams sponsored?

Do you lease employees?

Has there been a lapse in coverage during the past 12 months?

Work above or below 15 ft?

Have you had a bankruptcy in the past 7 years?

Are you a member of any trade organizations?

If yes, which organization?

Additional Information

Please provide any additional information you feel appropriate. The more information we have, the sooner a quote will be available. Thank you.