WorkComp Options
315 Ethan Walk
McDonough, GA30252
Contact:  ToddBowser  CWCP, CWCA
President
Phone: 
Fax:  877-282-8622
Cell:   
Email:  todd@workcompoptions.net
www.workcompoptions.net

Thank you for your interest in obtaining a quote for workers compensation from WorkComp Options.

 Below is a brief questionnaire for you to complete.  This questionnaire and the requested paperwork will provide the information needed for accurate applications for quotes from my carriers.  Please complete as much information as possible.

 If you have any questions please give me a call 678-481-4397. 

In addition to the completed questionnaire I will also need the following:

1.  Copy of current declarations/information pages from your policy or a copy of your renewal quote. (these pages will have class codes, payroll, debits, credits and the calculation of your premium)
2.  Experience MOD Worksheet from NCCI (1-800-NCCI-123)
3.  Loss runs for current policy period and the past 4 years.  (Must have a valuation date with the last 90 days.  If you do not have recently valuated loss runs we can get them for you.  Just be sure to fill out the Policy information section in the questionnaire below.

Fax the above information to 877-282-8622

Sincerely,


General Information

Company Name: 
 		  
Address: 
 		  
City:
 


 		 State:
 		     Zip:
 		    
Phone: 
enter as ###-###-####
 		  
Fax: 
enter as ###-###-####
 		  
Contact Name: 
 		  
Contact Title: 
 		  
E-mail: 
 		  
Website:   
How many years have you been in business?
 		  
SIC Code   
Federal ID Number: 
 		  
NCCI ID Number: 
 		  
Company Type:  Individual     Partnership     Corporation     S Corp     Limited Corp     Other
Please place an X in the box next to yourbusiness type                                                                                                                                              
 
Locations: 
Please list addresses of all physical locations of the company.		  
1.   
2.   
3. 
 		  
Proposed Effective Date: 
Enter as MM/DD/YYYY
 		  
Current NCCI Experience MOD: 
 		  
Current Yearly Premium: 
 		  
Amount of Deductible if you choose to have one: 
($500, $1,000, $1,500, $2,000, $2,500)		  


Rating Information
Location is the # from the location addresses above, payroll is yearly estimate.
1. State
 Location #
 Class Code:
   # of fulltime employees
 # of part-time employees
 Estimated Payroll
2. State
 Location
 Class Code:
   # of fulltime employees
 # of part-time employees
 Estimated Payroll
3. State
 Location
 Class Code:
   # of fulltime employees
 # of part-time employees
 Estimated Payroll
4. State
 Location
 Class Code:
   # of fulltime employees
 # of part-time employees
 Estimated Payroll


Officers Included/Excluded
List all officers of the company and whether they are to be included or excluded from coverage
1.  Name:     Included/Excluded(inc/exc)      Title:      Class Code 
     % of ownership        Estimated Remuneration        Date of Birth    State 
location          Duties
 
2.  Name:     Included/Excluded      Title:      Class Code 
     % of ownership        Estimated Remuneration        Date of Birth    State
Location        Duties
 
3.  Name:     Included/Excluded      Title:      Class Code 
     % of ownership        Estimated Remuneration        Date of Birth    State
Location        Duties
 
4.  Name:     Included/Excluded      Title:      Class Code 
     % of ownership        Estimated Remuneration        Date of Birth    State
Location         Duties
 
5.  Name:     Included/Excluded      Title:      Class Code 
     % of ownership        Estimated Remuneration        Date of Birth    State
Location        Duties 

Current/Past Policy Information
Year Carrier Policy Number Experience Mod Premium


Business Description:
Please provide a detailed description of your company and it's operations

 


Underwriting Questions
For your convenience we have pre-marked the answers "No".  Please read each question and change to "Yes" where appropriate using an "X".
1.  Does applicant own, operate or lease aircraft/watercraft? 16.  Are physicals required after offer of employment art made?
2.  Do/have past, present or discontinued operations involve(d) storing, treating discharging, applying or transporting of hazardous material: 17.  Any other insurance with this carrier?
3.  Any work performed underground or above 15 feet? 18.  any prior coverage declined/cancelled/non-renewed in last 3 years?
4.  Any work performed on barges, vessels, docks, bridge over water? 19.  Are employee health plans provided?
5.  Is applicant engaged in any other type of business? 20.  Is there a labor interchange with any other business/subsidiary?
6.  Are sub-contractors used? 21.  Do you lease employees to or from other employers?
7.  Any work sublet without certificates of insurance? 22.  Do any employees predominantly work at home?
8.  Is a formal safety program in operation? 23.  Any tax liens or bankruptcy within the last 5 years?
9.  Any group transportation provided? 24.  Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises?
10.  Any employees under 16 or over 60 years of age? Contact for engineering visit 
11.  Any seasonal employees?

Engineering contact phone number 

12.  Is there any volunteer or donated labor?

Engineering contact email address 

13.  Any employees with physical handicaps?

Contact for accounting purposes 

14.  Do employees travel out of state?

Accounting contact phone number

15.  Are athletic teams sponsored?

Accounting contact email address 

     

Contact for claims  

     

Claims contact phone number 

     

Claims contact email address 
 
For all questions marked "yes" please provide detailed explanations below.