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Call 1-866-935-6442
Request for Quote (RFQ)
Phone: 1-866-935-6442 Fax: 1-866-559-8744
 Updated 07.14.08
Client Profile
Please complete all of the information below:
Date:
Company  Name:
Phone:
Email:
Address:
City:
# Employees in Field: 
Federal ID/FEIN
Contact:
Fax:
Cell phone:
Web site:
State/Zip Code:
# Employees in Office:  
Is this a new business?: Yes No If no, how long?: 
Has this company ever carried workers comp insurance?: Yes No  
 
Insurance Agent/Broker Information:
Agent Name:
Phone:
Email:
Agency Name:
Fax:
Web site:
Required Documents for Quick Quote:
1. Signed RFQ w/Completed General Information Questionnaire.(This Form)Please  include FEIN or Federal ID
2. Detailed narrative on the company’s letterhead stating the nature of business. (at least one paragraph describing the company operations.)
3. Bio or short resume of business owner (Start-up business only)
4. Statement of “No losses” letter from Company owner/officer (Start-up business only)
  *Companies who have carried prior workers compensation coverage need to include these additional items
5. Three years of currently valued Loss Runs. Explanation of each loss in excess of   $10,000
6. Workers Compensation declaration page, or most recent audit summary, or if with a   leasing company, current invoice with each code listed. Annual payroll by class code.
7. Current Experience Modification report (if available)
Client Acknowledgement:
I declare that to the best of my knowledge the information provided in this application is true and acknowledge that the information in this Client Application will be supplied to the insurance company providing workers' compensation insurance coverage.  I understand that any person who knowingly and with intent to defraud any insurance company or another person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civil penalties.  [Not applicable in CO, HI, NE, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied. Completion and submission of this Request for Quote form extends iNeedComp.com and i Insurance Group written permission to send facsimile correspondence and or advertisements to the Representative at the number provided pursuant to FCC Telephone Consumer Protection Act as amended. I acknowledge I am requesting a quote from iNeedComp.com, a member of the i Insurance Group, Inc. , a broker for AMS Staff Leasing. I further acknowledge i have not requested a quote from another AMS Staff Leasing broker.
Completed By:
Date Completed:  
Payroll Breakout

Workers Compensation insurance premiums are based on payroll and job description (W/C Code). Therefore, it is extremely important that the underwriters have the estimated annual payroll by code/job description. Please provide a list of employee payroll by job classification. Be sure these are for all employees on an estimated yearly basis. See the example below.

 
Example
W/C Code - if known:
5551               
Job Description:
Roofing                  
Number of Employees:
10                 
Estimated annual Payroll:
$350,000               
GENERAL INFORMATION (Check box which applies)
Y N N/A
1 Is the applicant a subsidiary of another entity or have any subsidiaries?
Y N N/A
2 Is the applicant engaged in any other type of business?
Y N N/A
3 Does the applicant get involved in any of the following operations? Please mark appropriately.
Dam Construction, including cofferdams and caisson building
Levee or breakwater construction
Subway or Tunnel Construction
Railroad construction
Blasting
Environmental/pollution work
Asbestos abatement work
Trucking-interstate or transporting or disposing of hazardous waste
Chemical, petrochemical process, oil/gas well and nuclear work
Occupational disease exposure
Offshore drilling
Underground or coal mining of any type
Wrecking or demolition of structures, vessels or building exceeding two stories in height
Rocket or missile testing or launching
Sawmills or logging
Window cleaning in excess of two stories
Bridge construction or painting
Steel erection in excess of two stories
Scaffolding-leasing, erection, or repair
Sand or gravel digging
Pesticide operations involving fumigation or tenting
Crane operators
Repossessing services
Firearms
Y N N/A
4 Does the applicant own, operate, or lease aircraft/watercraft?
If so, is it used in day to day business operations?
Y N N/A
5 Is there exposure to flammables, explosives, or chemicals?
If so, what type of protection and preventative measures are used?
Y N N/A
6 Are there past, present, or discontinued operations that involve storing, treating, discharging, applying, disposing, or transporting of hazardous material?
If so, which ones? And what type of hazardous materials?
Y N N/A
7 Is work performed underground or above 15 feet?
if so, how deep is the confined space? If so, How high and is tie off equipment used?
Y N N/A
8 Is work performed on Barges, vessels, docks, or bridges over water?
If so, how often? What safety measures are in place?
Y N N/A
9 Is group transportation provided?
If so, what type of vehicle? How many employees use the transportation?
Y N N/A
10 Are any employees under 18 or over 60 years of age?
What are their job functions?
Y N N/A
11 Are there part time or seasonal employees?
How many?
Y N N/A
12 Is there volunteer or donated labor?
Y N N/A
13 Do employees travel out of state?
How far? How long?
Y N N/A
14 Is there current or past involvement with OCIP?
What percent of annual revenues?
Y N N/A
15 Are employee health plans provided?
Y N N/A
16 Does the risk hire subcontractors ?
What percent?
Y N N/A
17 Does the risk obtain Certificates of Insurance from all subcontractors?
Y N N/A
18 Does the risk require all subcontractors to carry primary limits equal to or greater than their own?
Y N N/A
19 Is the risk named as additional insured on all subcontractor’s policies?
Y N N/A
20 Does the risk use written subcontractor agreements containing hold harmless/indemnity agreements in favor of the risk?
Y N N/A
21 Does the insured verify that all subcontractors follow all industry requirements and applicable state and local codes?
Y N N/A
22 Does the insured use hot tar in their business?
If so, what percentage of the overall business is hot tar related?
Y N N/A
23 Does the insured carry General Liability insurance?
If so, what is the renewal date?
Y N N/A
24 Does the insured wish to obtain a free General Liability insurance quote?
If so, please contact our office?
Completed by:
Date completed:
   
 
 
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