Back to QUOTE FORMS Page Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  
ALL RIGHTS RESERVED

Workers Compensation
 Quote Form

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

 -   The "ENTER" or "RETURN" Key will submit the application.   Use the "TAB" Key and Mouse to navigate.
      If application is submitted by mistake, use the "BACK" Button on your browser to return to the application. 

 -   Allow up to 2 weeks to receive a quotation

GENERAL INFORMATION

Business Name:

 Phone:

Mailing Address:

 Contact:

City:

State:  Zip:  Fax:

County:

 Email:

Type of Entity:

C-Corp   S-Corp   LLC   Partnership   Sole Proprietor    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? N  Do employees travel out of state? Y  
 Any employees under 16 or over 60 years of age? N  Are Sub-Contractors Used? Y  N
 Are employee health plans provided? N  Any prior coverage cancelled? 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  

 

 CREATED 6/00 by
T.R.G.
Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: December 04, 2017 .