Your Logo and Company Information Here!

(color scheme will be changed to match yours)



    Pay As You Go Work Comp


     General Information

Name of Business:

Name of Owners/Officers:


Contact Name:

Contact Phone & Fax:

 Phone:    Fax:

Contact E-mail Address:





   State:    Zip:

Business Info:





 Years in Business:

Fed. Tax ID or Social Security Number:

Business Description:

     Current/Previous Insurance Information

Current insurance company:

   Annual Premium:

Policy Period:

 Effective Date:    Expiration Date:

Work Comp Modifier:

(if Known)

Will Owners be Included or Excluded- Please Explain:

Additional Owner Info:

Any Other Carriers

(last 3 years):


No  Yes   If yes, please list name and estimated premium:

Any Insurance Claims Filed

(last 3 years):




No  Yes   If yes, please give following data:

 -Date of claims, amount of claims, description, and cost of claims:

     Payroll  & Class Code Information

Class Code

or Job Description

# FT Employees

# PT Employees

Estimated Payroll

per Class Code

     Other Information

List any additional Locations:


Do You Require Coverage Above Mandatory Limits:

No  Yes   If yes, please describe required limits:

Do You Work Outside

 of Your State:

No  Yes 

Are you a current "Payroll Co" Client: No  Yes

     Additional Comments & Information

Please tell us anything else you think might be helpful to know in order to provide accurate insurance quotes:

Your company links back to your site will be here.