NHC Insurance Services: Customer Service - Quotes

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Customer Service: Quotes - Workers Comp Quote Request
IMPORTANT! Please Read Before Completing. By completing and submitting this form you agree that no coverage is bound and no policy is in effect until you are contacted by one of our representatives. All sections in red are required.

WORKERS COMPENSATION POLICY QUOTE REQUEST
BUSINESS INFORMATION
Business Name:
Contact Name:
Contact Title:
Phone:
Fax:
E-Mail:
Physical address:
Physical address2:
City:
State:
Zip Code:

Mailing address if different:
Address:
Address2:
City:
State:
Zip Code:

Federal ID # or Social Security Number:


Entity is:
Partnership Corporation	Sole Proprietorship Other - specify
If this entity is a Corporation or Partnership, list names and titles of ALL owners and their percentage of ownership below:


How were you referred to us?

OPERATIONS INFORMATION
Description of Business:

Duties of employees (not owners):

More than one location:
Yes No
If more than one location, list other locations below:

Years in business:


Any frequent travelling exposure for employees:
Yes No

Does Employer provide health insurance:
Yes No
If yes, carrier name:


What are your business hours:

PAYROLL INFORMATION
Number of Full time employees:
Full time employees duties:

Full time employees Class Code:
Full time employees annual payroll:

Number of Part time employees:
Part time employees duties:

Part time employees Class Code:
Part time employees annual payroll:
WORKERS COMPENSATION COVERAGE EXPERIENCE (select one)
Experienced & Insured*
Carrier name:
Renewal date of coverage:
Any claims in last 3 years:		Yes No
* You will need to forward NHC a copy of your loss history for the last three years.

True New Venture
Year business began:
1st employee hired date:
Years of management experience (in similar business):

Employees without coverage
First employee hired date:
Reason for no coverage:

Remarks and/or special instructions:


SUBMIT QUOTE REQUEST
Send my quotation via:
E-Mail Fax	Postal Mail Phone

We value your input as PRIVATE information. Every step has been taken to insure your privacy. Our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I agree.

Please review the information you have entered above carefully. When you are ready to send your data, click the button below. Please click only once. You should receive a response back from one of our highly qualified agents within 1-2 business days.