Description: Wokers Comp Insurance Quote , Workers Compensation Insurance, California Workers Compensation, Nevada Workers Compensation
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Workers Compensation Insurance Quote ( click here for a business owners / general liability policy) ABOUT THE OWNER / PRINCIPAL Company: First Name: Last Name: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carol
In this section, please describe the jobs at your company and the total annual salary paid for that position. (ex: secretary, $40000). If you know the class code, please enter it. CLASS CODE (optional) JOB TITLE Full Time Part Time GROSS SALARY Prior Carrier Information/ Loss History
If you had prior WC insurance, please fill out the information below Year Carrier # Policy # Annual premium # Claims Amount Paid: Workers Compensation Questionnaire YES NO 1. Does applicant own, operate or lease aircraft/watercraft? 2. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc) 3. Any work performed underground or above 15 feet?