WORKERS COMPENSATION INSURANCE QUOTE REQUEST
   
Type of quote:
Your full name: (required) 
Business name: (required) 
Business street address:  
City, State & Zip:  
E-Mail address: (required) 
Day telephone: (required) 
Eve telephone:  
Fax:  
Best time to reach you:
   
CURRENT INSURANCE INFORMATION
   
Do you have insurance now? (if not, skip this section)
Insurance company name: (not your agent or broker)
How long have you been insured with your current insurer? (mm/dd/yyyy)
Annual premium amount: $
Policy expiration date:
Policy number:
MOD factor:
Any claims in the past 3 years?

If yes, how many claims?
Total amount of claims paid: $

   
ABOUT YOUR BUSINESS OPERATIONS
   
Number of years in business:
Number of locations:
Federal Tax ID Number:
Total square feet you occupy:  
Projected gross annual sales: $
Number of full-time employees:
Number of part-time employees:
Projected annual payroll:
$
   
PAYROLL INFORMATION
   
Class Codes
Employee duties

Number of Employees
Annual Payroll
$
$
$
$
       
BUSINESS OWNER INFORMATION
   
Owners' Name(s)
Date of Birth
(mm/dd/yyyy)
Title
Ownership %
       
GENERAL INFORMATION
   
Do you offer safety programs?
Do you offer health benefits to the majority of your employees?
Do you employ any minors (under the age of 18)?
Do you use sub-contractors?
Do you use any equipment that bends, shapes or forms?
Are any athletic teams sponsored?
Has there been a lapse in coverage during the past 12 months?
Do employees ever work above 15 feet off the ground?
Has the business filed bankruptcy in the past 7 years?
Are you a member of any trade organizations?
   
COMMENTS, QUESTIONS OR ADDITIONAL INFORMATION WE SHOULD KNOW
 

No coverage of any kind is bound or implied by submitting information via this online form.

  • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

YES! I Agree


© 2008 Canyon Insurance Agency. All Rights Reserved.
Site Design by Groves Burrus Associates