Insurance Workers' Compensation Renewal Quote

INSURANCE WORKERS' COMPENSATION RENEWAL QUOTE

Quote Information

Quote Number:   Date of Quote:

Renewal Effective Date:   Expiration Date:

Prior Policy Number:   Underwriting Contact:

Insured / Applicant Information

Phone:   Email:

Federal Tax ID / FEIN:   State of Operation:

Policy & Coverage Details

Policy Type: Workers' Compensation Employers' Liability Stop-Gap Coverage

Deductible / SIR:   Estimated Annual Payroll:

Experience Modification Factor (Mod):   Loss Cost Multiplier / Rate:

Premium Summary & Payment

Manual Premium:   Estimated Premium (Before Audit):

Current Premium:   Proposed Renewal Premium:

Audit Basis: Payroll Gross Receipts Other

Coverages, Endorsements & Options

Standard Coverages Included: Statutory Workers' Compensation Employers' Liability

Optional Endorsements: Waiver of Subrogation Additional Insured Terrorism Coverage Voluntary Compensation

Exclusions & Limitations

The quote is subject to the policy terms, conditions, exclusions and endorsements of the issuing carrier. Typical exclusions include but are not limited to:

• Intentional acts, fraud, or willful noncompliance with safety statutes;
• Liability arising from non-covered jurisdictions or uninsured operations;
• Claims outside the scope of statutory workers' compensation benefits;

Loss History (Most Recent 3 Years)

Policy Year:   Payroll:   Losses (Count / Incurred): /

Policy Year:   Payroll:   Losses (Count / Incurred): /

Policy Year:   Payroll:   Losses (Count / Incurred): /

Required Documentation Checklist

3-year loss runs provided

Prior declarations page(s)

Recent payroll reports / payroll register

Safety program / written procedures

Beneficiary / Payee for Refunds (If Applicable)

Relationship to Insured:   Percent of Refund:

Declaration & Certification

I certify that the information provided in this renewal quote request is true, correct and complete to the best of my knowledge. I understand that this document constitutes a quote only and does not bind coverage. Coverage, if issued, will be governed by the terms, conditions, exclusions and endorsements of the policy forms issued by the insurer and is subject to acceptance of the application, inspection, verification of payroll and other underwriting information, and receipt of premium. Premium stated is an estimate and is subject to audit and adjustment in accordance with the policy provisions. Any changes to the operations, payroll, classifications, or loss exposures subsequent to issuance may result in additional premium or endorsement changes.

By signing below, the undersigned acknowledges receipt of this renewal quote and requests issuance of the renewal policy consistent with the terms contained herein. Acceptance of this quote and issuance of a policy are subject to final underwriting approval and payment of premium; no coverage exists unless and until the insurer issues a policy and effective date is established on a signed policy or binder.

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