Harris - Worker Comp Quote

Worker Compensation Quote

You will be contacted within 1 business day by our agent

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION
Your Name:	First: Last:
Business Name:
E-Mail address:
Phone numbers:	Day Time:
	Evening:
	Fax:
How would you prefer to be contacted regarding your quote?	PhoneFaxEmail
If you would prefer to be contacted by phone, please let us know the best time to call.

Mailing Address:
City:
State:
Zip code:

Social security number
Corp/ LLC EIN#:(Federal Employer Number)
Proposed Effective Date:
Years in Business	(If in business a year or more we need a copy of 1099 to get a quote)

Business Locations
	Enter street, city, county, state, zipcode
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#2
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Owners, Partners,Officers, Relatives to be included
Name	Date of Birth	Title/Relationship	Duties	Excluded

	Rating Information
Loc #	Job Description	Num of Employees	Annual Payroll

Prior Carrier Information (If no prior coverage, please provide resume of experience (remark section))
Company Name	Year	Annual Premium	Policy Number

General Information (explain all yes reponses in remarks)
1. Does applicant own, operate, or lease aircraft/watercraft?
2. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)
3. Any work performed underground or above 15 feet?
4. Any work performed on barges, vessels, docks, bridge over?
5. Is applicant engaged in any other type of business?
6. Are sub-contractors used? (if yes give % of work subcontracted)?
7. Any work sublet without certificates of Insurance?
8. Is a written safety program in operation?
9. Any group transportation provided?
10. Any employees under 16 or over 60 years of age?
11. Any seasonal employees?
12. Is there any volunteer or donated labor?
13. Any employees with physical handicaps?
14. Do employees travel out of state?
15. Are athletic teams sponsored?
16. Are physicals required after offers of employment are made?
17. Any other insurance with this insured?
18. Any prior coverage declined/canceled/non-renewed(Last 3 years)?
19. Are employee health plans provided?
20. Is there a labor interchange with any other business/subsidiary?
21. Do you lease employees to or from other employers?
22. Do any employees predominantly work at home?
23. Any tax liens or bankruptcy with the last 5 year?


Remarks (Including description of business)