6.  Online Submission Form:

Name of Business:

Name of Owners/Officers:

Contact Name:

Contact Phone & Fax:

 Phone:    Fax:

Contact E-mail Address:

Address:

City:

   State:    Zip:

Business Info:

C-Corporation
S-Corporation
LLC                

Sole-Proprietor

Partnership

LLP/Other

 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:

List owner's 1) social security numbers, 2) date of births, and 3) percentage of ownership.

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:

1: 2: 3:

Do You Require Coverage Above Mandatory Limits:

No  Yes   If yes, please describe required limits:

Do You Work Outside

 of Your State:

No  Yes 

     Additional Comments & Information

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