ARG & Associates will provide you with a free, no-obligation Workers' Compensation Insurance quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote.

Workers' Compensation Insurance

Company Information

Company Name:                    Date:

Contact:

Address:

City:

State:

Zip:

Phone:                                Best time to call:   am    pm

Fax:

E-mail:

Insurance Information

Currently Insured with:

Policy Number:            Policy Expiration Date:

Premium Amount: $       Insured Amount: $

Term of Insurance:  6 months    1 year    other:

What other types of insurance coverage do you have relating to your business? (Please list below):

Insurance Type                              Premium paid per Year                      Expiration Date

Business Liability                         $

Business Auto                             $

Business Umbrella                       $

Workers' Compensation                $

Professional Liability                     $

Liability for Corporate Executives   $

Group Health                               $

Group Life                                   $

Group Retirement/401k/etc.          $

Surety Bonds                              $

Company Financial Information

What was your past years Annual Income: $    Projected Current Year Income: $

What was your past years Annual Payroll: $   Projected Current Year payroll: $

How many years has the company been in business?

How many Full Time employees do you employ?

How many Part Time employees do you employ?

Do you have any contract labor?  Yes    No, if yes, how many contractors do you have?

Employee List
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If you require additional space please reset form after you send original information reuse form as many time as needed to complete your information. Please only fill in company name at the top and in the contact space fill in page number. (Example: Contact: Page 3 of 4)

List of Excluded Employees
Name:                                                 Title/Percent of Ownership:             Compensation:
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If you require additional space please reset form after you send original information reuse form as many time as needed to complete your information. Please only fill in company name at the top and in the contact space fill in page number. (Example: Contact: Page 3 of 4)

Business Operation/s
Please list the duties and types of work your company performs in the space provided below:
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If you require additional space please reset form after you send original information reuse form as many time as needed to complete your information. Please only fill in company name at the top and in the contact space fill in page number. (Example: Contact: Page 3 of 4)

Additional Details

Please list below any additional details in the space provided below:

When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly.

      

  This Form: WCI2002 is a Copyright © 2003 First e-Commerce Corporation