Worker's Compensation Questionnaire
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Business Name:

Select One: Sole Proprietor Corporation ('S') Corporation ('C') Corporation (LLC) Partnership

Contact Person:

Address - Street:

Address - Mailing:

City: State: Zip:

Phone: Fax: Email:

Please contact us by: Phone Fax Email

Type of Business:

Gross Payroll:

Please describe your business -

Number of Employees Current Carrier:

Exp. Date: Current Agent:

Gross Sales: WC Experience Mod:

If you operate in more than one state, list all other states:

Please divide your payroll into the following:

8810 Clerical - Payroll:

8742 Drivers - Payroll:

Outside Salesmen - Payroll:

Other classes you have divided by payroll:

Class: Payroll: Class: Payroll: Class: Payroll:

Are owners/officers to be included or excluded from coverage:

Include Exclude

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