Contractor Insurance for Colorado
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Worker's Compensation Insurance - Information Request Form
Company Info
Why so much information?
Contact Name
*Company Name Required
Address
*Address Required
Company Name
*Company Name
City
*City Required
Company Type
Sole Proprietor
Partnership
Corporation
LLC
Other
Zip Code
*Zip Code Required
# of Owners, Members, or Officers
Email
*Email Required
*Must be valid email addr.
Do the Owners Wish to be Covered?
Yes
No
Phone
*Phone Number Required
Underwriting Info
EIN #
Currently Insured?
Yes
No
Please Describe Work Performed by Employees (classification groups)
Name of Carrier
Emp. Group 1 (Classification)
How Long Insured
Group 1 - Annual Payroll
Claims for past 3 years - Provide details / dates
Group 1 - # of Employees
Emp. Group 2 (Classification)
Group 2 - Annual Payroll
Group 2 - # of Employees
Emp. Group 3 (Classification)
Group 3 - Annual Payroll
Group 3 = # of Employees
Emp. Group 4 (Classification)
Group 4 - Annual Payroll
Group 4 = # of Employees
