TrustPoint Insurance - Workers Compensation</span>

Who we represent:

WORKERS COMPENSATION INSURANCE QUOTE REQUEST
Contact Information
*Name:
Address:
Business Name
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
*Email Address:

Underwriting Information
What is the nature of your business?	Nature of Business
Is the business a corporation, partnership or sole proprietorship?	Corporation Partnership Sole Proprietorship
How many owners?	Number of Owners
How many employees?	Number of Employees
What is the payroll amount of the owners?	Payroll of Owners
What is the payroll amount of the employees?	Payroll of Employees
What is the total annual gross?	Total Annual Gross Receipts
What is the business license number?	Business License Number
What is the license type?	License Type
Years of experience in this business?	Years of Experience
How many years have you operated under your current business name?	Years Operated Under Current Name
Have you used any other business names during the past 5 years?	Other Business Names	Yes No
Is this business open 24 hours a day	Open 24 Hours	Yes No
Any deep frying (food)?	Deep Frying	Yes No
Is there any manufacturing, mixing, re-labeling or repackaging of products?	Manufacturing	Yes No
Is there filling of propane tanks?	Propane Tank Filling	Yes No
Please describe the nature of your business and ANY unusual exposures.	Unusual Exposures

Payroll Detail Information
	Class/Code	Payroll Rate	Annual Payroll
Employee Group 1
Employee Group 2
Employee Group3
Employee Group 4
Employee Group 5

Claims Information
Were there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?	Amount Current Premium
What is the liability limit requested?	Liability Limit

Questions,Comments or Additional Coverage

Please be advised that coverage cannot be bound, altered or amended by leaving a message at this web site. Please contact the local Trustpoint office that handles your account and our associates will be happy to assist you.