Workers Compensation Insurance - Don Williams & Associates

Business Name*
Date Business Opened*
Type of organzation*
- Sole Properiter
- LLC (Limited Liability Compnay)
- Corporation
- Not-for_Profit
Primary Contact Name*
First Last
Cell Phone
Email*
Business Address (mailing address)*
Street Address City State ZIP Code
Description of Business Operations*
Please briefly tell us what your company does. Make sure to include any specialty within an industry. For example, if you are a concrete company, please don't simply state "construction" as your industry. We adapt to your specific trade.
Number of Employees (counting yourself)*
Annual Payroll (excluding what you pay yourself)*
Gross Annual Receipts*
Workers Compensation
Current Insurance Company
Experience Modifier ( E-Mod)
Additional Notes
Any Additional Notes
Please list any additional information you believe we may need to know. For instance, if you business has multiple workers compensation class codes we would need to know the amount of payroll applicable for each class code.

Workers Compensation

No items found.