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Ramsgate Insurance

HOME
SOLUTIONS
ABOUT
NEWS
CONTACT US
AGENT/BROKER/REP
CLIENT CENTER
- CLIENT CENTER LOGIN
- CONTACT CLIENT CARRIERS

Workers Comp Quote Form

YOUR WHOLESALE INSURANCE SOLUTION

Workers Comp Quote Form

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GET STARTED

Do you have completed Acords (125, 130)? *

Please describe your client's business operations. *

SIC/NAICS Codes are helpful.

RATING STATE/S

Rating State/s *

Choose multiple states if necessary. Use the Shift Key.

Policy/Form Type

AGENCY/BROKERAGE CONTACT INFORMATION

Business Name

Primary Contact First Name *

Agent/Broker/Rep

Primary Contact Middle Name

Agent/Broker/Rep

Primary Contact Last Name *

Agent/Broker Rep

Phone

Agent/Broker/Rep

Contact Email1 *

Agent/Broker/Rep

YOUR CLIENT'S BUSINESS LOCATION INFORMATION

Business Name *

Include DBA, if applicable.

Address Line 1 *

Clients Business Information

Address Line 2

Clients Business Information

City *

Clients Business Information

State Code *

Clients Business Information

Zip Code *

Clients Business Information

Business Phone *

Clients Business Information

Business Ext

Clients Business Information

Business Fax

Clients Business Information

Date Business Started

MM/DD/YEAR

Federal Tax ID/SSN

Clients Business Information

What is the legal structure of your client's business? *

Clients Business Information

Does your client's business have a website? *

Clients Business Information

Website URL *

Clients Business Information

YOUR CLIENT'S BUSINESS OWNER/CONTACT INFORMATION

Primary Contact First Name *

Clients Business Information

Primary Contact Middle Name

Clients Business Information

Primary Contact Last Name *

Clients Business Information

Mobile Phone

Clients Business Information

Contact Email2 *

Clients Business Information

GENERAL POLICY INFORMATION

Is your client business currently insured? *

Policy Status *

Start-Up or Expired?

Requested Effective Date of Policy *

Current insurance carrier. *

Current premium amount paid.

Reason Policy Expired

Previous Carrier *

Previous premium amount paid.

Has your customer's business had any claims? *

Claims include fire, burglary, flooding, vandalism, etc.

Number of claims in past 3-5 years *

Number of full time employees. *

Number of part time employees. *

What are the gross receipts for your client's business?

What is the annual revenue for your client's business? *

Target/Estimated Premiums *

COVERAGE FOR YOUR CLIENT'S BUSINESS

Expiring/Requested Liability Limits *

Including/Excluding Officer/s *

Total Payroll Including Officer/s *

Total Payroll Excluding Officer/s *

Risk Classes, Number of Employees Per Risk Class, & Annual Payroll for Each Class

DOCUMENTS

Do you have all Acords on one file? *

Acord 125 Form *

Acord 130 Form *

Acord 125 & 130 Forms *

Declarations Page of Expiring/Expired Policy

Supplemental

Loss Runs (3 years Preferred/5 years Hard to Place)

Quote Needed for Additional Lines of Business?

BOP
General Liabililty
Commercial Property
Commercial Umbrella/Excess
Commercial Auto
EPL, D&O, Fiduciary, Crime & Tech Professional Liability
Miscellaneous Errors & Emissions (E&O)
Inland & Ocean Marine
Fidelity & Surety Bonds
Owners & Contractors, and Railroad Protective - Construction Risk Only
Business Travel Accident (BTA)
Cyber Liability
Other Not Listed

CERTIFY INFORMATION

Certify *

Yes

I understand that the information provided herein is essential and material to the agency/brokerage relationship and herby certify the above answers are truthful and accurate, to the best of my knowledge.

Comment

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