Workers' Comp Questionnaire | RealCare Insurance Marketing

Legal Business Name:
DBA:
Contact Name:
Phone
Email
Mailing Address:
Location Address:
Do you have multiple locations:
- Yes
- No
Type of Ownership (corp, individual)
FEIN
Description of Operations (Professional Services):
Date Business Started:
Date Format: MM slash DD slash YYYY
Years of Industry Experience:
Number of Full Time Agents and/or Employees (including 1099 ):
Number of Part Time Agents and/or Employees (including 1099 ):
Do you perform Property Management Services?
- Yes
- No
If yes, please detail services provided and which members of the firm are involved in property management.
Projected Annual 1099 Commission and/or Payroll:
How much of the above 1099 Commission and/or Payroll is for Property Management Services?
Owner Excluded from Workers’ Compensation Coverage?
- Yes
- No
Currently have Workers’ Compensation coverage?
- Yes
- No
If Yes, please provide Loss Runs for up to four previous years:
Carrier Policy Dates Premium Payroll # of Losses
Any prior coverage declined, cancelled or non-renewed in the past three years?
- Yes
- No
List any claims within past 3 years.

Carrier	Policy Dates	Premium	Payroll	# of Losses

Workers’ Comp Questionnaire