Commercial Insurance Quick Questionnaire

What Insurance are you applying for: (check all that apply)

Contact Information

Applicant Information

Number of Years in Business

Number of W2 Employees – Do not include owners

Number of 1099 Employees – Do not include owners

Payroll

Please provide the gross Annual Payroll for the following

Current Policy Information

Experience Modification Factor –   Definition - An adjustment of an employer's premium for worker's compensation coverage based on the losses the insurer has experienced from that employer.

Comments

Please email a Copy of most recent 5 year loss run