Insurance Workers Comp Quote

INSURANCE WORKERS COMP QUOTE

Quote Number:    Date Prepared:

Applicant / Insured Information

Employment / Payroll Details

Payroll Basis:    Estimated Annual Payroll:

Policy Details / Quote Summary

Policy Type:    Audit Basis:

Coverage Options

Workers' Compensation — Statutory Benefits
Employers Liability — Limit:
Other States Coverage
Voluntary Compensation
Stop-Gap Coverage (if applicable)

Exclusions and Endorsements

The following standard exclusions and endorsements apply to this quote unless otherwise noted. Check any requested endorsements to be added:

Exclusion: Intentional Acts
Exclusion: Independent Contractor Misclassification
Endorsement: Employee Leasing / Professional Employer Organization (PEO)
Endorsement: Waiver of Subrogation (subject to carrier approval)

Required Documentation Checklist

The following documents are required prior to policy binding and are subject to carrier review. Check documents provided:

Copy of current workers' compensation policy (if any)
Loss runs for prior 3 years
Recent payroll records or payroll projections
Signed application for coverage

Conditions, Limitations and Important Notice

This quote is an estimate prepared solely for the prospective insured identified herein. It is based upon representations made by the applicant and available underwriting information as of the Date Prepared. This quote does not bind coverage, create a contract, or obligate the insurer to issue a policy. Coverage will be effective only upon issuance of a policy document and receipt of any required premium and underwriting documentation.

Premium is estimated and subject to adjustment following a post-issuance audit or as otherwise permitted by policy terms and applicable law. Failure to fully disclose payroll, classification, operations or claims history may result in premium adjustment, endorsement, or cancellation in accordance with policy terms. The insurer reserves the right to impose additional exclusions, endorsements or rating modifications based on carrier underwriting criteria.

Additional Information

Declaration and Certification

I certify that, to the best of my knowledge and belief, the information provided in this quotation request is true, correct and complete. I understand that this quote is an indication of terms and estimated premium only and that final underwriting approval, policy terms, conditions and premium are subject to the insurer's review of all required documentation and verification of information. I authorize the insurer and its authorized representative to obtain and exchange loss history and underwriting information necessary to evaluate this request.

I acknowledge that premium may be subject to state assessments, taxes, fees and adjustments required by law or regulation. I agree to cooperate with post-bind audits and to provide accurate payroll records upon request.

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