contractors insurance underwriter
 
 

Workers Comp Survey

Company Name:

Contact Person:   Title:

Mailing Address:

City/State/Zip:

Phone: Fax: Cell:

Email Address: License # (Contractors only):


Current Agent Name: Phone: Email:

Total Contractor Employees: Total Non-Contractor Employees:

Total Contractor Payroll $ Total Non-Contractor Payroll $

Five Year Data by Year:

Year: Premium: # of Claims: Total Incurred:

Year: Premium: # of Claims: Total Incurred:

Year: Premium: # of Claims: Total Incurred:

Year: Premium: # of Claims: Total Incurred:

Current Carrier: Experience Modification Factor: Renewal Date:

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