Workers Compensation Form

Are you the policyowner?(Required)

If no, what is your relationship to the policyowner? If yes, type "NA"(Required)

Note: All questions hereafter pertain to the policyowner.

The Quote Form is our preliminary process of obtaining the necessary underwriting information. Be as thorough as possible. The current policy and claim history will also be required as part of the underwriting process.

Full Name(Required)

First Last

Primary Phone Number

Email(Required)

Mailing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Legal Name of Business(Required)

Nature of Business(Required)

# of Years in Business:(Required)

# of Years of Consecutive Insurance Without a Lapse:(Required)

Physical Address of Business, Leave Blank if Same as Mailing(Required)

Street Address City State / Province / Region ZIP / Postal Code

Estimated Annual Gross Receipts(Required)

How many owners, members or officers?(Required)

Estimated Annual Payroll(Required)

Number of Full-time Employees(Required)

Number of Part-time employees(Required)

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Are Subcontractors Used?(Required)

If Subcontractors are used, do you verify that they have insurance?(Required)

Estimated Annual Cost of Subcontractors? Or Type "NA"(Required)

Do you currently have insurance?(Required)

If yes, Name of Insurance Carrier. If no, type "NA"(Required)

Has there been a lapse in coverage in the last 3 years?(Required)

Any Special Requirements?(Required)

If yes, please explain special requirements. If no, type "NA"(Required)

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Has your company had any claims in the past 3 years?(Required)

If YES, please provide brief explanation of claims. If no, type "NA"(Required)

How did you hear about us? Please let us know(Required)

Is there anything else that you would like for us to know concerning your up and coming Renewal?

SIGNATURE REQUIRED

I have provided all of the above information for insurance purposes and I state all information is true to the best of my knowledge. I also understand that I am to discuss with the agent at D. Ward Insurance my desired limits and coverage.

By typing my name warrants my signature.(Required)

First Last

ADDITIONAL INFORMATION NEEDED

Please note - if the Business is insured, a copy of the policy and claim history will be required. They can be obtained from your current agent by requesting the documents to be sent electronically to you. Thank you for time and we will be in touch with you today unless this is after hours or on the weekend - Debbie Ward and Valerie Moore

ENTER VALIDATION CODE

For Security of your personal information, enter code and press submit

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Workers Compensation Form

Note: All questions hereafter pertain to the policyowner.

SIGNATURE REQUIRED

ADDITIONAL INFORMATION NEEDED

ENTER VALIDATION CODE

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