Contractor Insurance for Colorado

Worker's Compensation Insurance - Information Request Form

Company Info

Why so much information?
Contact Name Address
Company Name City
Company Type Zip Code
# of Owners, Members, or Officers Email
Do the Owners Wish to be Covered? Phone

Underwriting Info

EIN # Currently Insured?
Please Describe Work Performed by Employees (classification groups) Name of Carrier
Emp. Group 1 (Classification) How Long Insured
Group 1 - Annual Payroll Claims for past 3 years - Provide details / dates
Group 1 - # of Employees
Emp. Group 2 (Classification)
Group 2 - Annual Payroll
Group 2 - # of Employees
Emp. Group 3 (Classification)
Group 3 - Annual Payroll
Group 3 = # of Employees
Emp. Group 4 (Classification)
Group 4 - Annual Payroll
Group 4 = # of Employees