Form : Workers Compensation Insurance Quote Fill in the form below and Matrix will contact you with custom proposalCompany Name: First & Last Name: * Street Address: City, State & Zip: E-Mail Address: * Telephone: Fax: Current Insurance InformationInsurance 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 InfoInsurance Company Name: # of claims: Claim amt. pd $: Premium Amount: How many years: 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: WholesalerRetailerManufacturerContractorServiceOther Please describe your business here: Owners / Partner / OfficersName Date of Birth Title Ownership % Name1 Date of Birth1 Title1 Ownership%1 Payroll InformationClass Codes Employee Duties Annual Payroll $ Hourly Wage $ Class Codes1 Employee Duties1 Annual Payroll $1 Hourly Wage $1 Class Codes2 Employee Duties2 Annual Payroll $2 Hourly Wage $2 General InformationExplain All “Yes” Responses1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT? YesNo if yes 2. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) YesNo if yes 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? YesNo if yes 4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER? YesNo if yes 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS? YesNo if yes 6. ARE SUB-CONTRACTORS USED? (IF YES, GIVE % OF WORK SUBCONTRACTED) YesNo if yes 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.? YesNo if yes 8. IS A WRITTEN SAFETY PROGRAM IN OPERATION? YesNo if yes 9. ANY GROUP TRANSPORTATION PROVIDED? YesNo if yes 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE? YesNo if yes 11. ANY SEASONAL EMPLOYEES? YesNo if yes 12. IS THERE ANY VOLUNTEER OR DONATED LABOR? YesNoOption 3 if yes 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS? YesNo if yes 14. DO EMPLOYEES TRAVEL OUT OF STATE? YesNo if yes 15. ARE ATHLETIC TEAMS SPONSORED? YesNo if yes 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? YesNo if yes 17. ANY OTHER INSURANCE WITH THIS INSURER? YesNo if yes 18. ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED (Last 3 years)? YesNo if yes 19. ARE EMPLOYEE HEALTH PLANS PROVIDED? YesNo if yes 20. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY? YesNo if yes Additional InformationPlease 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 until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information VerificationPlease enter any two digits with no spaces (Example: 12) *This box is for spam protection - please leave it blank