Workers' Comensation Insurance Quote - Greater Insurance Service,

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WORKERS' COMPENSATION QUOTE

WE PROVIDE INSURANCE COVERAGE FOR MINNESOTA ONLY
To obtain a FREE, no obligation quote for Workers' Compensation, fill out the form below and we will contact you. If you prefer to give information over the phone, fill out the * areas only and we will give you a call, or print this out and mail or fax it to us.

Name:	*
Address:	*
City:	*
State:	*
ZIP:	*
Home Phone:	*
Email:	*
Work Phone:
Cell Phone:
Federal ID #:
Many of the companies we represent require the following information prior to providing a firm quote. To provide an accurate quote we need to ask questions about yourself and members of your family. The information collected enables us to receive information from consumer reporting agencies, motor vehicle departments, and inspection services. This information is available to the insurance companies who provide the insurance rates used in the quoting process.
Type Of Business Entity:	Sole Proprietorship Partnership Corporation Limited Liability Corporation
Number of Employees: Full Time Part Time

A breakdown of your payroll by work-classification will be required.
Annual Payroll $ Carpentry - Class Code 5403 Annual Payroll $ Excavation - Class Code 6217 Annual Payroll $ Clerical - Class Code 8810 Annual Payroll $ Logging - Class Code 2702 Annual Payroll $ Trucking - Class Code 7228 Annual Payroll $ Plumbing - Class Code 5183 Annual Payroll $ Electrical - Class Code 5190 Annual Payroll $ Other
Limits: 100/500/100 500/500/500
States of Operation:
Do you have individuals that you want excluded from coverage? These would include partners, officers, and relatives. If so, please list them here and make sure that they are not included in the payroll figures listed above. Also be aware that any work-comp related loss suffered by any of these excluded individual will not be covered by the work-comp policy.

Please provide us with your current Experience Modification Factor:
Do you have current loss runs or claims experience reports from your current insurer? Yes No We can provide a quote based on your verbal disclosure of any prior claims but we cannot guarantee the rate or bind the coverage until we have documents indicating your loss experience for the three prior years.
What is the name, policy number and date of renewal of your current insurance company?
Do you have sub-contractors working for you? Yes No If you have subs you will need to obtain certificates of insurance from them in order to verify that they have their own coverage in-force and to eliminate the possibility that they could be included in your payroll totals and subsequent premium calculations.
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