Workers Compensation

WORKERS COMPENSATION QUOTE FORM
Are you the policyowner? Required	Yes No
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.
First Name Required
Last Name Required
Primary Phone Number Required
E-Mail Address Required
Mailing Address Required
City Required
State Required	AL GA NC SC TN
ZIP / Postal Code Required
Legal Name of Business Required
Nature of Business Required
If Corporation or LLC, provide Federal ID # Required
Physical Address of Business or Type "Same as Mailing" Required
City, State, ZIP Code or Type "NA" Required
How many owners, members or officers? Required
Estimated Annual Gross Receipts Required
Estimated Annual Payroll Required
Number of Full-time Employees Required
Number of Part-time employees Required
Are Subcontractors Used? Required	Yes No
If Subcontractors are used, do you veritify that they have insurance? Required	Yes No No Subcontractors Used
Estimated Annual Cost of Subcontractors? Or Type "NA" Required
Do you currently have insurance? Required	Yes No
If yes, Name of Insurance Carrier. If no, type "NA" Required
Has there been a lapse in coverage in the last 3 years? Required	No, there has not been a lapse in coverage. Yes, there has been a lapse in coverage.
Any Special Requirements Required	Yes No
If yes, please explain special requirements. If no, type "NA" Required
Has your company had any claims in the past 3 years? Required	Yes No
If YES, please provide brief explanation of claims. If no, type "NA" Required
PLEASE LET US KNOW
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 quote request? Optional
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
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
Submission Validation Required	Enter the Validation Code from above.

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Insurance Websites Designed and Hosted by Insurance Website Builder