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Williams Insurance Services

 

Workers Comp Quote Request

 

 

 

 

 

Business Name:*

 

 

Mailing Address:

 

 

City:

 

 

State:

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

Physical Address
(if different from above)

 

 

City:

 

 

 

State:

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

Contact Person:

 

 

 

Phone Number:

 

 

Fax Number:

 

 

Email Address:*

 

 

Website:

 

 

Year Business Started:

 

 

FEIN:

 

 

Description of Business:

 

 

Type of Business Entity:

 

 

INDIVIDUAL:

 

 

 

Name (First and Last)

 

 

SSN:

 

 

Percent of ownership

 

 

 

 

 

 

 

 

 

 

 

If Married, MUST have:
Spouse (First and Last)

 

 

SSN:

 

 

Percent of ownership

 

 

 

 

NOTE: The company requires spouse if individual as they will run that there are no outstanding policies or monies due. In past, either husband or wife had set up policy-it cancels- then other spouse would start a policy.

 

 

 

 

 

 

 

 

 

 

PARTNERSHIP: (Each Partner)-also include % of ownership for each

 

 

 

Name (First and Last):

 

 

 

SSN

 

 

 

 

Percent of Ownership

 

 

 

 

 

 

 

 

 

Name (First and Last):

 

 

 

SSN:

 

 

 

 

Percent of Ownership:

 

 

 

 

 

 

 

 

 

CORPORATION: (Each officer) - also include title and % of ownership for each

 

 

Name (First and Last):

 

 

SSN:

 

 

 

 

Percent of Ownership:

 

 

 

 

 

 

 

 

 

 

 

Name (First and Last):

 

 

SSN:

 

 

 

 

Percent of Ownership:

 

 

 

 

 

 

 

 

 

 

 

Name (First and Last):

 

 

SSN:

 

 

 

 

Percent of Ownership:

 

 

 

 

 

 

 

 

 

 

LLC: (Each Member) - also include who is MANAGING MEMBER and % of ownership for each

 

 

Name (First and Last):

 

 

 

 

SSN:

 

 

 

 

Percent of Ownership:

 

 

 

 

 

 

 

 

 

 

 

Name (First and Last):

 

 

 

 

SSN:

 

 

 

 

Percent of Ownership:

 

 

 

 

 

 

 

 

 

 

 

Name (First and Last):

 

 

SSN:

 

 

Percent of Ownership:

 

 

 

 

 

 

Number of Employees:

FT         PT  

 

 

 

 

 

 

Type of Work Being Performed:

If multiple types of work, will need breakdown of employees and payroll for each type.

 

 

 

 

 

 

 

 

 

Prior Coverage:

 Yes   No

 

 

 

YES= We must have loss run

 

 

 

NO= Unless it is a new business-we will need a brief summary of
why they haven't carried insurance, and now have the interest to do so.

 

 

         

 

 

 

 

 

 

 * Indicates required field

 

 

 

 

 

 

 

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