Contractor Insurance for Colorado
Home
General Liability
Worker's Comp
Commercial Auto
Surety Bonds
About Us
Worker's Compensation Insurance - Information Request Form
Company Info
Why so much information?
Contact Name
Address
Company Name
City
Company Type
Sole Proprietor
Partnership
Corporation
LLC
Other
Zip Code
# of Owners, Members, or Officers
Email
Do the Owners Wish to be Covered?
Yes
No
Phone
Underwriting Info
EIN #
Currently Insured?
Yes
No
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