Workers Compensation Insurance Quote Form in Fort Worth, Texas

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Workers Compensation Insurance Quote Form
	First & Last Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:
	Current Insurance Information
Insurance Company Name:
Any losses in last 3 years?:
# of claims:		Claim amt. pd $:
Premium Amount:		Policy Exp. Date:
MOD Factor:		Policy #:
Describe the type of Coverage you currently have:
	Prior Carrier Info
Insurance Company Name:
# of claims:		Claim amt. pd $:
Premium Amount:		How many years with:
MOD Factor:		Policy #:
	About Your Business
# of Full-time:		# of Part-time:
Owner's Name:		Fed Tax ID:
License Type:		Yrs in Business:
License #:		# of locations:
Annual Gross Sales:		Square Footage:
Est payroll / mo.:		Type of Business:
Please describe your business here:
	Owners / Partner / Officers
Name	Date of Birth	Title	Ownership %



	Payroll Information
Class Codes	Employee Duties	Annual Payroll $	Hourly Wage $




	General Information
Do you offer safety programs?
Do offer health benefits to majority of employees?
Do employ any minors (under 18)?
Operation all/part of exist. business purch/acq?
Do you use subcontractors?
Use any equipment that bends/shapes/forms?
Are athletic teams sponsored?
Been a lapse in coverage during past 12 months?
Any work above 15 feet?
Had a bankruptcy in past 7 years?
Are a member of any trade organizations?
Additional Information: Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.

Note: By submitting this form you understand that no coverage is bound unitl you receive written notice.

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Lucien Wright Insurance Services, Inc. 1200 West Freeway, Suite 200 Fort Worth, TX 76102 Phone: (800) 280-5900 Email ecommerce@lucienwright.com