Keefe Insurance Agency - Contractors Workers Compensation Quick-Quote Application

Contractors Workers Compensation Quick-Quote Application

*Your Name:
*Business Name:
*Mailing Address:
*City:
*State:
*Zip:
*Phone:
E-mail Address:
Website:
Legal Entity:
Describe your contracting operation in detail:

Name the Owners, Corporate Officers, Partners or LLC members and work they perform::
Annual payroll not including Owners, partners and corporate officers::
Number of Full-time employees:
Number of Part-time employees:
Currently Insured?:	Yes No
Name of insurance company
policy renewal date
current premium
how long insured
Current policy information if available
Payroll Class #1 list Class code if you know it and describe	Payroll $
Payroll Class #2 list Class code if you know it and describe	Payroll $
Payroll Class #3 list Class code if you know it and describe	Payroll $

* Required information