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Friday	8:00 AM - 4:00 PM

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Daniels/Nicolson Insurance Agency, Inc. Worker's Compensation Quote

Worker's Compensation
24-Hour Request-A-Quote Form

Your First Name:

Your Last Name:

Business Name:

License #:

Email Address:

Fax Number:

Phone Number:

Enter the number of claims reported during the past 12 months:
If you have state-assigned Experience Modification, enter here:
Do you currently have worker's comp insurance?
If yes, what is your current company?

Organization

	Corporation
	Partnership

	Individual
	Sub-Chapter 'S'

STEP #1: Choose your current work comp category(ies) by code number or class name using the drop down menu of your choice below. If you can't find your code please call.

STEP #2: Read the description below. Does it match your business? If YES, Click the button below the description box.

VERIFY DESCRIPTION

STEP #3: The code you selected now appears in one of the boxes below (see black column). Now type the ANNUAL PAYROLL in the box to the right of the code (red column).

STEP #4: If you have more than one (1) class code, go back to step one and repeat the steps until all applicable codes have been selected and their respective annual payroll(s) entered.

YOUR SELECTIONS	CLASS CODE	ENTER PAYROLL
CLASS CODE #1		STEP #1
CLASS CODE #2		STEP #1
CLASS CODE #3		STEP #1
CLASS CODE #4		STEP #1
CLASS CODE #5		STEP #1
CLASS CODE #6		STEP #1
CLASS CODE #7		STEP #1

Yes	No
		Have there been any Arizona Osha citations?
		Has there been any lapse in coverage for over 30-days in the past 12 months?
		Does owner/manager have less than 3-years experience in this trade?
		Any Bankruptcy Filings (Ch.7, 11)?
		Will the perspective employees have less than 1-year of average experience in this trade?
		Any work performed 15-feet or more above or below the ground?
		Any work sublet without certificates of insurance?
		Any work performed outside Arizona?
		Are there any employee-leasing, PEO, or labor interchange exposures of any kind?
		Is any work performed on roofs or does any work require the use of pressurized combustible gases?
		Do you sub-contract over 50% of gross receipts?

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Daniels/Nicolson Insurance Agency, Inc. Worker's Compensation Quote