APLAZ Group Inc

Workers Comp Quote Request

Workers Comp Insurance Quote Request from Aplaz Insurance Services

Items denoted with a red asterisk(*) represent required fields.

Contact Name *

Primary Owner Name *

Business Legal Name *

Business DBA *

Address

City

State

Zip *

Phone Number *

Ext

Fax

Email Address *

Underwriting

Nature of Your Business

Federal Employer ID *

Current WC Insurance Carrier

Multi-State Employer

Renewal Date

Medical Insurance Provided

Payroll

Annual Gross Payroll

Number of Owners

Total Payroll of Owners

Number of Employees

Total Payroll of Employees

Exclude Owners

Class Code

WC Rate

Annual Payroll

Employee Group 1

Employee Group 2

Employee Group 3

Employee Group 4

Employee Group 5

Business Background

Years of Experience

Years Operating This Business

Business License City *

Business License Type *

Business License Number *

Who does your payroll?

Risks

Are you open 24 hours a day?

Do you deep fry foods?

Do you fill propane tanks?

Please provide a "loss value run" report from your current WC carrier. Other comments regarding your business which may effect WC coverage.

Claims and Losses For Last Five Years

Description

Amount($)

Are you a robot? *

“Disclaimer” I understand that this form, merely informs Aplaz of a proposal request and is not a Policy of Insurance, Application or Offer to Insure on behalf of any Insurance Company, Agency or Agent. Individual companies reserve the right to accept, reject or modify a proposal after investigation and review.