Customer Information

Company Name:
First Name:	Last Name: *
E-Mail:	*
Phone:	*

Address:	*
City, State and Zip Code:	*
Effective Date:	*
County:	*
Year Business Established:	*
Legal Entity:	Choose Corporation Individual Limited Liability Co Partnership Association - Corporation Association - Limited Liability Co Condo Owner - Corporation Condo Owner - Limited Liability Co Joint Venture - Corporation Joint Venture Limited Liability Co Non Profit - Corporation Non Profit - Limited Liability Co Other - Corporation Other - Limited Liability Co Other - Partnership
Federal Employer ID:

Rating Information

Coverage Effective Date:	*
Type of Business:	*
Number of Workers Compensation losses in the prior 3 years *
Prior Carrier (if any):	*
Number of Employees: (All full and part time employees  included in the payroll)	*
Do you have employees in other states?	- Yes No *
If so, which states

 

Policy  /  State Information

	Accident  -  Limit  -  Employee
Employer Liability Limits:	- --100,000-----500,000-----100,000 --500,000-----500,000-----500,000 --1,000,000-----1,000,000-----1,000,000 *
Experience Modification Factor:  (if Known)	(x.xx)
NCCI ID # (if Known)

Class Information

Class Code (If Know)	Class Description	Annual Payroll

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