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Workers Compensation Form
Contact Joey: Call 843-577-7898 - Fax 843-577-7899
Or Send Email to:
wjjutzeler@bellsouth.net
Please Print and Fax the following form to 843-577-7899 for a quote
| Owner(s) / Officer(s) Position(s)
|
| Company Name: |
| Mailing Address: |
| Phone/Fax #'s |
| Year Business Started Years Experience in Field |
| Entity (Circle) Individual Partnership Corporation LLC |
| Federal ID / Tax ID SS# |
| Owners: Include Exclude Use Subcontractors? Yes No |
| Number of Employees: Payroll: (Exclude Owners) |
| How do you pay employees? (Circle) 1099 W-2 |
| Current Insurance Company: Expires: |
| Detailed Description of Business
|
| Any losses over last 4 years: |
| Experience MOD Rating: |
| Other Items that may be needed: 4 year loss history Experience Rating Sheet Copy of Current Policy/Renewal |