Workers Compensation

Name*

First Last

Email*

Business Name

Address

Street Address City Kentucky or Tennessee only ZIP Code

We only insure Kentucky and Tennessee

Phone

Fax

Business Type

Industry

Describe your Business

Annual Gross Sales

Number of Full Time Employees

Number of Part Time Employees

Estimated Monthly Payroll

Number of Locations

Years in Business

Federal Tax ID

License Type

License Number

Number of Owners

Owner Name	Date of Birth	Title	Ownership %

Do you offer safety programs?

Do you offer health benefits?

Do you employ any minors?

Do you use sub-contractors?

Do you use any equipment that bends/forms/shapes?

Do you sponsor any athletic teams?

Do you do any work up over 15 feet?

Is the business open 24 hours?

Is the business involve any deep frying of foods?

Is the business involve any filling of propane tanks?

Have you filed bankruptcy in the past 7 years?

Are you a member of any trade organization?

Current Carrier Name

Policy Expiration

Current Premium Amount

MOD Factor

Coverage Description

Has coverage lapsed in past 12 months?

New Coverage Liability Limit

Number of Losses Claimed in the Past 5 Years

Loss/Claim Description	Date of Incident	Amount of Claim

Agent Name (Optional)

How Did You Hear About Us?

Preferred Contact Method

Additional Comments

Contact Us

Personal Lines

Business

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