Workers Compensation Insurance Quote Form

Workers Compensation
Quote Form

Limited Availability Per State. Please email: insurance@thompsongusic.com or call 412-271-8888 to check availability.

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-   Allow up to 2 weeks to receive a quotation

GENERAL INFORMATION

Business Name:		Phone: This # isCell Biz Home
Mailing Address:		Contact:
City:	State: Zip:	Fax:
County:		Email:
Type of Entity:	C-Corp S-Corp LLC Partnership Individual Other:	Quote Need by Date:
Year Business Established:	Website:	Federal ID Number (FEIN):

Brief Description of Operations:
-Additional Space is available below in Comments Section

POLICY INFORMATION

CHECK IF NO PRIOR INSURANCE
Current Carrier: Expiration Date: Current Premium:

RATING INFORMATION (from current policy, if available)

STATE	You may leave this blank unless codes are known CLASS CODE	DESCRIPTION - Job Duties (ie: Office, Guide, Retail)	EMPLOYEES # Full Time	EMPLOYEES # Part Time	ANNUAL PAYROLL

OFFICER / LLC MEMBER / OWNER INFORMATION

Name	Title (ex: Pres)	% of Ownership	Included or Excluded	Duties	Annual Payroll
			Include Exclude
			Include Exclude
			Include Exclude
			Include Exclude

SUPPLEMENTAL INFORMATION

Any work done underground or above 15 feet?	Y N	Do employees travel out of state?	Y N
Any employees under 16 or over 60 years of age?	Y N	Are Sub-Contractors Used?	Y N
Are employee health plans provided?	Y N	Any prior coverage cancelled?	Y N

LOSS INFORMATION - Past 3 Years

# of claims over past 3 years:
                   0
                   1 - 5
                   6 - 10
                   10+

         No one (1) paid claim was more than:
                             $1,000
                             $5,000
                             $10,000
                             $15,000 +

Have there been any lost time claims?
Yes No

The above information is correct to the best of my knowledge. Check: Initials:

ADDITIONAL COMMENTS / INFORMATION

QUESTIONS / HELP	Contact Pittsburgh Office
Phone:	(412) 271-8888 8:30am - 4:30pm EST Mon-Fri
Fax:	(877) 271-8898
Email:	insurance@thompsongusic.com