Worker’s Compensation Premium Estimate

Customer Name *

Office Phone *

Mobile Phone

Mailing Address *

Mailing Address

City

State/Province

Zip/Postal

Website/URL

Email

Entity Type

Year Business Card

Federal Employer ID Number *

Description of Operations *

Locations

Location Number *

Highest Floor *

Address *

Address

City

State/Province

Zip/Postal

Add Remove

Policy Information

Proposed Effective Date

Proposed Expiration Date

Normal Anniversary Rating Date

Part 1 – Workers Comp (States)

Text

Part 2 – Employer’s Liability

$100,000 / $500,000 / $100,000

$500,000 / $500,000 / $500,000

$1,000,000 / $1,000,000 / $1,000,000

Experience/Merit Modification

State

Factor

Expiring/Target Premium

Individuals Included/Excluded

Partners, Officers, Relatives (Must be employed by business operations) To be included or excluded (Remuneration/Payroll to be included must be part of rating information section.) Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.

State

Location Number

Name

Date of Birth

Title/Relationship

Ownership %

Duties

Include

Exclude

Class Code

Renumeration

Add Remove

State Rating Worksheet

Location #

Class Code

Categories, Duties, Classifications

# of Full-time Employees

# of Part-time Employees

Payroll

$

Add Remove

Loss History

Please list all claims from the past 5 years. Date / Type / Amount Paid