Corporate Office
795 Woodlands Parkway • Suite 101
 Ridgeland, MS 39157
Tel: (601) 914-3220 • Fax: 914-3188

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Online Workers Compensation Quote Request

To receive your personalized Workers Comp insurance quote, please COMPLETE and SUBMIT the following questionnaire.

All information received is kept fully confidential and is used for quoting purposes only.

TERMS: By submitting this completed form you understand there is no coverage in force until an application is approved and premium is received by the insurance company.  You certify that the statements made on this quote request are accurate to the best of your knowledge.  This Web site should not be construed as a solicitation of any sort in any jurisdictions other than those in which the agency holds a license and is authorized to transact business.

General Business Information
*Business Name:

*Your Full Name:
*Your E-mail Address:

Business Address:

City:
State:     Zip:
Phone:
FAX:
How Many Years In Business:
How Is Your Business Structured:
Federal Employer ID Number:

 

Locations
Inform us of your current Business Location details,
including each location's Street, City, County, State & Zip Code

:


,

:


,

:


,

:


,

 

New Policy Information

Proposed Effective Date:

Employers Liability:

 $ Each Accident
$ Disease-Policy Limit
$ Disease-Each Employee

 

Rating Information

State

Class Code

Categories, Duties, Classifications

# Employees

Estimated Annual Remuneration

Full Time

Part Time

Experience Modification:

Factor

Factored Premium

$

 

Individuals Included/Excluded
 Partners, Officers, Relatives to be Included or Excluded.

#

Name

Date Of Birth

Title/Relationship

Ownership %

Duties

Include/Exclude

 

Prior Carrier Information/Loss History
Provide information for the past 5 years and use the remarks section for loss details.

Year

Carrier

Policy Number

MOD

# Claims

Amount Paid

Reserve

$

$

$

$

$

$

$

$

$

$

Remarks: Provide Loss Details if Applicable

 

Nature of Business/Description of Operations
 Give comments and descriptions of business, operations and products:  Manufacturing - Raw Materials, Processes, Product, Equipment, Contractor - Type of Work, Sub-Contracts, Mercantile - Merchandise, Customers, Deliveries, Service - Type, Location, Farm - Acreage, Animals, Machinery, Sub-Contracts.

 

General Information
Explain all "YES" responses.

QUESTION

YES

NO

1. Does your business 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 water?

5. Are you 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?

QUESTION

YES

NO

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 insurer?

18. Any prior coverage declined/cancelled/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 within the last 5 years?

24. Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises?  If YES, explain including entity name(s) and policy numbers(s).

Explain All YES Answers From Above

 

Additional Comments
 Please leave any comments or additional entries here.

Click "Submit Request" to send your completed quote request.

One of our representatives will respond to you as soon as possible.
Thank you for giving us the opportunity to serve you.

Note: By submitting this completed form you understand that there is no coverage in force until an application is approved and premium is received by the insurance company.  You certify that the statements made on this quote request are accurate to the best of your knowledge.  This Web site should not be construed as a solicitation of any sort in any jurisdictions other than those in which the agency holds a license and is authorized to transact business.