WC & GLI

NC Workers Comp & General Liability Insurance Quote
Effective Date

MonthDayYear
Business Owners Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-Mail*
Email
Business Entity*
Business Name / DBA*
Company Name
Federal Employer's ID *
Description of Operations or SIC code*
Business Description
% Commercial / % Residential
% New Construction / % Remodel
What type of safety equipment is used?
Safety glasses, hard hats, steel boots, etc.
Max. height work is done?
Max. weight lifted?
Any sub-contracting done?
Business Website
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business Owners # of years working in the field?*
Owners experience
Total # of years in Supervision/Management of employees (in any field)*
Owners experience
# of years in Supervision/Management of employees (in current field)*
Owners experience
If new in business, name of company where experience was acquired supervising employees and briefly describe your responsibilities?
Owners experience
NOTE: Ineligible if no prior insurance and not new in business.
Years in Business*
Current Insurance Carrier
Current Policy Expiration Date
Current Policy #
Any losses in the past 3 years *
Description of losses or loss runs
# of full-time employees*
# of part-time employees*
# of locations*
Experience Mod (if any, per policy)
Estimated Annual Revenue (Receipts)*
Estimated Annual Owners Salary*
Estimated Annual Payroll*
Comments
This quote form is not a contract or binder of insurance. To apply for insurance, you must complete the application process. Insurance subject to terms, conditions and availability. Your actual premium may be higher or lower based on a number of factors, including: additional information you provide or we obtain from consumer reporting agencies or other publicly available sources; the coverages, limits and the deductibles you choose; any applicable discounts;additional underwriting and rating criteria; and, depending on your state, the date coverages are purchased or the date coverages become effective. To learn more, please contact your local agent at Amistad Insurance Services (919) 926-7166.
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NC Workers Comp & General Liability Insurance Quote

NOTE: Ineligible if no prior insurance and not new in business.