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 form is hosted on a secure server using SSL technology.

 

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: Individual Corporation Partnership Joint Venture   Years in Business:   # Emp: Business Tax ID Number: Website Address: Been insured w/ Erie Insurance?: Yes No 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 (or current) 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: --Select One-- Frame Stucco Masonry/Brick Fire Resistive Other 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): Amount of Coverage Desired: $100/$500/$100 $500/$500/$500 $1,000,000/$1,000,000/$1,000,000

Coverage Limits Building: Contents (inventory, supplies, etc.): Computers & Equipment: Deductible: Loss of Income: $ $ $ --Select One-- $100 $250 $500 $1,000 $ Money and Securities: Glass or signs: General Liability Limit: Non-owned and Hired Automobile Liability: Is liquor liability needed? $ $ --Select One-- $500,000 $1,000,000 $2,000,000 $ Yes     If Glass Coverage is needed, please provide dimensions:     Please list other coverages you may need:

Employee Information Name Full Time/ Part Time DOB Years Employed Classification Code or Job Description Estimate Yearly Payroll F P $ F P $ F P $ F P $ F P $ F P $ F P $ F P $ F P $ F P $ 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 Is ther a safety program in place?:    Yes 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.

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