June 24, 2017 i
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Information Disclosure
In order to provide you with an accurate quote from one of our insurance carriers, we may need to collect information from consumer reporting agencies, such as driving record, claims, and credit history reports.
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Contact Information
Contact Name Primary Owner's Name
Business Legal Name Business DBA
Address City
State Indiana Kentucky Zip
Phone Email
Fax
CURRENT/PRIOR INSURANCE INFORMATION
Nature of Your Business Federal Employer ID
Current Insurance Carrier Current WC Premium
Renewal Date Liability Limit Requested
FINANCIAL BACKGROUND
Annual Gross Revenue Number of Owners
Total Payroll of Owners Number of Full Time Employees
Total Payroll of Employees Number of Part Time Employees
Experience Modification Factor:
Class Code Workers Comp Rate Annual Payroll
State
Employee Group 1 IN KY
Employee Group 2 IN KY
Employee Group 3 IN KY
Employee Group 4 IN KY
Employee Group 5 IN KY
BUSINESS BACKGROUND
Years of Experience Years Operating This Business
Business License City Business License Type
Business License Number
Who does your payroll?
Other comments regarding your business which may effect WC coverage.
CLAIMS AND LOSSES FOR THE LAST FIVE YEARS
Description Amount($)

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