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WORKERS COMPENSATION

Workers Compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence. The tradeoff between assured, limited coverage and lack of recourse outside the worker compensation system is known as "the compensation bargain."

While plans differ between jurisdictions, provision can be made for weekly payments in place of wages, compensation for economic loss, reimbursement or payment of medical and like expenses, functioning in this case as a form of health insurance, and benefits payable to the dependents of workers killed during employment..

General damages for pain and suffering, and punitive damages for employer negligence, are generally not available in workers' compensation plans, and negligence is generally not an issue in the case.

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Contact Name:
Address:
City:
State/Providence
Zip/Postal Code
Phone:
Email:
Fax
Company Name:
Policy Expiration Date: (mm/dd/yyyy)
List type of coverages
Quote(s) needed for: Bond Commercial
Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers Comp
Other

Business Information

 
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?

Please give a brief description of your business and clientele

Property/Premises Information

Address
Occupancy Status
Year Built
% Occupied
Sprinklers

Stories

# Basements
Sq. Footage
Burglar Alarm
Building Value
Contents
Other Property (specify)

Insurance Information

 
Annual Gross Sales: (before taxes)

Number of Employees

Annualized Payroll

Cost of any Subcontracted Work

Limits Requested

Describe any claims you've had in the past 5 years

Additional Comments