Business Insurance Quote

Current Policy Information
Workers Compensation Insurance Company:
Workers Compensation Premium:
Workers Compensation Expiration Date:
Are You Currently Recieving a Workers Compensation Dividend?	Yes No
Have you already reviewed your NCCI Experience Modification Factor?	Yes No

**Workers Compensation Undewriting**
	Employee Duties/ Classification	Class Code (if Known)	Number of Employees	Annual Payroll
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Additional Underwriting Questions
Have you been cancelled, non-renewed oe declined for insurancein the past 3 years?
Has the applicant had a foreclosure, repossession, bankruptcy, judgment or lien in the past 5 years?
Has the applicant been involved in any lawsuits, or had any judgements or leins against them in the past 5 years?
Are any other business operations owned by the applicant, or any owners of the applicant company?
Do you have a formal safety program?
Do you check employees' Motor Vehicle Records prior to hire?
Would you like ALC Risk to quote any other lines of insurance for you?
What other lines of insurance would you like a quote for?

Additional Information Please list additional vehicles, drivers or other pertinent information to help expidite the underwriting process.