Home

WORKERS' COMPENSATION 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.

    
This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication.

Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

 
General Information
Name of Business:
Owner's Name:
Location Address:
City:   State:   Zip:
Is the mailing address the same as the location address? Y N
Mailing Address:
City:   State:   Zip:
Business Phone:   Fax:
Contact Email Address:
Business Status:   Years in Business:   # Emp:
Business Tax ID Number:
Website Address:
Been insured w/ Erie Insurance?: Yes
State(s) conducting business in?:

How Did You Hear About Us?
Please check all that apply:
Search Engine Social Network Advertisement Family or Friend
Forum/Blog Co-Worker Other:

Current Insurance Information
Please provide information on previous insurance carrier:
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
NCCI #:
NCCI Experience Modification #:
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  
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:     Premium: $
Carrier Name:     Premium: $

Property Questions
Age of building
/Year Built:
Type of building
construction:
Number of
stories:
Other
occupancies:
Square feet
you occupy:
sq. ft.
If the building is over 25 years old, please answer the following:
Year Electricity was updated:

Is it on circuit breakers?:

Yes

Year Plumbing was updated:

Copper or Galvanized plumbing?:

Copper   Galvanized   Other:

Year Building was last re-roofed:

Type of roofing material:

Type of heating system in the building:

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):

Coverage Limits
Building:
Contents (inventory,
supplies, etc.):
Computers &
Equipment:
Deductible:
Loss of Income:
$
$
$
$
Money and
Securities:
Glass or signs:
General Liability
Limit:
Non-owned and Hired
Automobile Liability:
Is liquor
liability needed?
$
$
$
Yes
    If Glass Coverage is needed, please provide dimensions:
    Please list other coverages you may need:

Employee Information
Employee#
Classification Code or Job Description
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
Delievery Service
Pre-employment Physicals
Offer Safty and Incentive programs
Other  

Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:    Yes
Have you ever been named in litigation regarding faulty construction?:    Yes
Are there any claims or legal actions pending?:    Yes
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:    Yes

Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years.
This information is kept strictly confidential

Are there any claims or legal actions pending?    Yes

Claim #1
  Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
  Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2
  Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
  Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

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.

   


Online Forms by ENHANCED Web Services
This Workers' Comp Quote Form Copyright © 1998 - by ENHANCED Web Services

All Rights Reserved Oberryman Insurance Services, LLC
Website Terms & Conditions