Todd W. Balderson BIA, LLC
Workers Compensation Quote Form
Name of Business:
Contact Person:
E-Mail Address:
Street Address:
City:
State: Texas.
Zip:
Work Phone:
Fax:
Cell Phone:
Home Phone:
Company
Information
Business Type:
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Please Select One
Individual
S-Corp
Partnership
Corp.
Other:
Federal Tax ID:
If Individual, Owner SS#:
Spouse SS# :
Years in Business:
License#:
License Type:
Owners/Partners/
Corporate Officers
Name
Date of Birth
Title
Ownership %
Prior Carrier
Year
Carrier
Policy #
Annual Prem.$
MOD Factor
# Claims
Claim Amount Paid $
Payroll
Information
Number of Employees
Class Codes
Employee Duties
Full Time
Part-time
Annual Payroll $
Hourly Wage $
General
Information
>
Please Select
Yes
No
Do you offer safety incentive programs?
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Please Select
Yes
No
Do you offer health benefits to majority of employees?
>
Please Select
Yes
No
Do you employ any minors (under 18)?
>
Please Select
Yes
No
Was this operation all or part of an existing business that was purchased or acquired?
>
Please Select
Yes
No
Do you use subcontractors?
>
Please Select
Yes
No
Do you use any equipment that bends, shapes, or forms?
>
Please Select
Yes
No
Are athletic teams sponsored?
>
Please Select
Yes
No
Do you lease employees?
>
Please Select
Yes
No
Has there been a lapse in coverage during the past 12 months?
>
Please Select
Yes
No
Work above or below 15 ft?
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Please Select
Yes
No
Have you had a bankruptcy in the past 7 years?
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Please Select
Yes
No
Are you a member of any trade organizations?
If yes:
Additional Information
Please provide any additional information you feel appropriate.
The more information we have, the sooner a quote will be available. Thank you.
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