Johns Insurance Agency, Inc. -- Workers' Compensation Quote Form


Workers' Comp INSURANCE QUOTE		We would like to provide you with a free, no-obligation Workers' Compensation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Business:
Contact Name:
Address:
City:	State: Zip:
Business Status:	Other:
Business Tax ID Number:
Business Phone:	Fax:
Best Time To Call:	AM PM
Contact Email Address:

Current Insurance Information

Company Name (not agency):

Policy Expiration Date: Premium Amount: $

NCCI Number: NCCI Experience Modification Number:

What type of coverages do you currently have:

Bond
Commercial Auto
Commercial Liability
Commercial Property Commercial Umbrella
Directors & Officers Liability
Disability
Group Health Group Life
Professional Liability
Other

About Your Business

# of full-time
employees # of part-time
employees How long
in business How many
locations Estimated Annual
Payroll

years $

Please give a brief description of your business(below):

Employee Information.

Employee# Classification code Estimate Yearly Payroll
1
2
3
4
5

Please list additional employees in the "Additional Comments" section below

Business Information

Please select all that apply to Business:

Operate or Lease aircrafts/watercrafts
Store, treat, dispose or transport hazardous waste
Work Underground
Work above 15ft.
Work on vessels, docks or bridges over water
Require out of State travel Use Subcontractors
Delivery Service
Pre-employment Physicals
Offer Safety and Incentive programs
Other

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

About Your Business
# of full-time employees	# of part-time employees	How long in business	How many locations	Estimated Annual Payroll
		years		$
Please give a brief description of your business(below):

Employee Information.
Employee#	Classification code	Estimate Yearly Payroll
1
2
3
4
5
Please list additional employees in the "Additional Comments" section below