Premier Services - The Insurance Experts

Workers Compensation Insurance Application
(Quotes will be provided for Pennsylvania, New Jersey, New York, Maryland and Delaware)

Contact name:

Company:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Company information

Is this company a:

List the total annual payroll for each class job description. An example may be sales-office type of business. There will be clerical duties and then there may be outside sales. You would list the total payroll for all the clerical and the total payroll for outside sales. If you already have a workers compensation policy and would like a competitive quote based on your current policy then you should add the 3 digit class code of each job description.:

Job class description 1:

Class Code 1:

Yearly payroll amount 1:

Job class description 2:

Class Code 2:

Yearly payroll amount 2:

Job class description 3:

Class Code 3:

Yearly payroll amount 3:

Job class description 4:

Class Code 4:

Yearly payroll amount 4:

If the business is incorporated, please list the payrolls of the active officers and job descriptions:

Officer 1: job class description:

Yearly payroll amount 1:

Officer 2: job class description::

Yearly payroll amount 2:

Officer 3: job class description::

Yearly payroll amount 3:

Officer 4: job class description::

Yearly payroll amount 4:

Policy limits: change if not basic:

Each accident:

Other amount:

Disease-policy limit:

Other amount:

Current insurance carrier:

Effective date:

Premium paid:

Please explain any claims against you in the past five years. Please include date, amount of claim, and details:

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What was the price quoted?

How did you hear about us?

Additional Comments: