Quote and Issue NOW
Home
About Us
Our Products
Our Locations
Our Staff
Customer Service
Manage Your Policy
FAQ
Auto
Home
Our Partners
Get a Quote
Contact Us
Welcome to Johnson Insurance Management. *** See our privacy statement under get a quote**
Workers Compensation Quote
PLEASE FILL OUT THE FORM BELOW AND SUBMIT FOR A FREE NO-OBLIGATION QUOTE FOR YOUR WORKERS COMPENSATION INSURANCE NEEDS:
NORTH CAROLINA RESIDENTS ONLY.
* = Mandatory
Name: *
Leave Blank:
Title:
Address 1: *
Address 2:
City: *
State: *
Select State
----------
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code: *
Organization:
Home Phone: *
Work Phone:
Fax:
Email: *
URL:
General Information
Years In Business: *
SIC Code:
Federal Employer ID Number:
NCCI ID Number:
Type of
Individual
Business: *
Partnership
Corporation
Subchapter 'S' Corp
Limited Corp
Other
Please explain all "Yes" answers
Does applicant own, operate or lease aircraft/watercraft: *
Yes
No
Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous materials
(e.g. landfills, waste, fuel tanks, etc)
: *
Yes
No
Any work performed underground or above 15 feet: *
Yes
No
Any work performed on barges, vessels, docks, bridge over water: *
Yes
No
Is applicant engaged in any other type of business: *
Yes
No
Are sub-contractors used: *
Yes
No
If Yes, give % of work sub-contracted:
Any work sublet without certificates of insurance: *
Yes
No
Is a formal safety program in operation: *
Yes
No
Any group transportation provided: *
Yes
No
Any employees under 16 or over 60 years of age: *
Yes
No
Any seasonal employees: *
Yes
No
Is there any volunteer or donated labor: *
Yes
No
Any employees with physical handicaps: *
Yes
No
Do employees travel out of state: *
Yes
No
Are athletic teams sponsored: *
Yes
No
Are physicals required after offers of employment are made: *
Yes
No
Any other workers comp insurance in force: *
Yes
No
Any prior coverage declined/cancelled/non-renewed
(Last 3 years)
: *
Yes
No
Are employee health plans provided: *
Yes
No
Is there a labor interchange with any other business/subsidiary: *
Yes
No
Do you lease employees to or from another employer: *
Yes
No
Do any employees predomintly work at home: *
Yes
No
Nature of Business/Description of Operations
(Give comments and descriptions of business, operations, and products: manufacturing--raw materials, processes, product, equipment, contractor--type of work, sub contracts, mercantile--merchandise, customers, deliveries, service--type, location, farm--acreage, animals, machinary, sub-contracts)
: *
Prior Carrier Information/Loss History
Provide information for the past 5 years and use the remarks section for loss details
Year:
Company:
Policy #:
Annual Premium:
MOD:
# Claims:
Amount Paid:
Reserve:
Remarks:
Year:
Company:
Policy #:
Annual Premium:
MOD:
# Claims:
Amount Paid:
Reserve:
Remarks:
Year:
Company:
Policy #:
Annual Premium:
MOD:
# Claims:
Amount Paid:
Reserve:
Remarks:
Year:
Company:
Policy #:
Annual Premium:
MOD:
# Claims:
Amount Paid:
Reserve:
Remarks:
Year:
Company:
Policy #:
Annual Premium:
MOD:
# Claims:
Amount Paid:
Reserve:
Remarks:
Individuals Included/Excluded
Partners, officers, relatives to be included or excluded (Remuneration to be included must be part of rating information section)
Name:
Date of Birth:
Title / Relationship:
Ownership %:
Duties:
Inc/Exc:
Class Code:
Remuneration:
Name:
Date of Birth:
Title / Relationship:
Ownership %:
Duties:
Inc/Exc:
Class Code:
Remuneration:
Name:
Date of Birth:
Title / Relationship:
Ownership %:
Duties:
Inc/Exc:
Class Code:
Remuneration:
Name:
Date of Birth:
Title / Relationship:
Ownership %:
Duties:
Inc/Exc:
Class Code:
Remuneration:
Name:
Date of Birth:
Title / Relationship:
Ownership %:
Duties:
Inc/Exc:
Class Code:
Remuneration:
Rating Information
State:
LOC:
Class Code:
Company Use:
Categories, Duties, Classifications:
# Employees Full Time:
State:
Estimated Annual Remuneration:
Rate:
Estimated Annual Premium:
State:
LOC:
Class Code:
Company Use:
Categories, Duties, Classifications:
# Employees Full Time:
State:
Estimated Annual Remuneration:
Rate:
Estimated Annual Premium:
State:
LOC:
Class Code:
Company Use:
Categories, Duties, Classifications:
# Employees Full Time:
State:
Estimated Annual Remuneration:
Rate:
Estimated Annual Premium:
State:
LOC:
Class Code:
Company Use:
Categories, Duties, Classifications:
# Employees Full Time:
State:
Estimated Annual Remuneration:
Rate:
Estimated Annual Premium:
Specify Additional Coverages / Endorsements
(If needed)
:
Additional space for additional classifications, information, etc
(If needed)
:
How would you like to receive your quote:
Email
Telephone
Fax
US Mail
