Carter & Company, L.L.P. 

 

 

 

  (If not in Texas, please click here to view a list of states in which we currently have non-resident licenses.
If your state is not listed then we would not currently have a market for you.)

Workers' Compensation
Workers' Compensation Insurance Quote
For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

General Information
Name of Business:
Inspection Contact Name:
Mailing Address:
City: State:   Zip:
Location Address:
City: State:   Zip:
Business Phone:   Fax:
Contact Email Address:
*Social Security # or *FEIN: *Required for quote by insurance companies
Business Status:     Years in Business:

Current Insurance Information
Carrier Name:     Premium: $
Effective Date:   Expiration Date:

Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:     Premium: $
Carrier Name:     Premium: $

No Previous Coverage

Please explain below if you have not had previous Workers' Compensation coverage:
 

Project/Work Information

  Please write a Description of Operations below:
 

Owner/Executive Information

For each owner and executive officer please supply names, dates of birth, percentage of ownership, and if they are to be included, their annual remuneration. Please provide the same information on each spouse since this is a community property state. Please indicate which owner/officers are to be included or excluded.
Name AND Title:
Date of Bith:
% of
Ownership:
Include or
Exclude:
Payroll:
%
 Incl. Excl.
$
%
 Incl. Excl.
$
%
 Incl. Excl.
$
%
 Incl. Excl.
$

Employee Information

How many employees are there?:
What is your annual estimated payroll by class excluding owners and officers?: $
How many years have you been in business?:
Have you had insurance in the past 3 years?: Yes No

If you answered "Yes" above, please be sure you listed the name of the insurance company (not agent) and effective dates in the Current Insurance Information section further up this form. We will ALSO need official "loss runs". Our Fax Number is: (830)875-9362.
  Please describe your hiring, training, and safety practices below:
 
Do you have a safety manual?: Yes No

If you answered "Yes" above, please fax a copy of the table of contents to: (830)875-9362.
What Employers' Liability Limit do you prefer?:
$100,000 / $500,000 / $100,000   Minimum
$500,000 / $500,000 / $500,000   1% extra
$100,000,000 / $100,000,000 / $100,000,000   2% extra
$ / $ / $

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

 

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