Please fill in the following information and someone will contact you within the next business day. Your business must be located in Vermont in order for us to provide you with a quote.

Your Information
Name of Business:
Contact Name:
Address:
City:
State:	Zip:
Contact Email:
Business Phone:
Preferred Method of Contact:	Email  Phone
Website Address
Federal ID # (FEIN) *Required
Chamber Membership #
Business Information
Desired Effective Date
Current Estimated Annual Comp Premium
How Many Years in Business
Legal Entity	Corporation Partnership Individual Other
Nature of Businee/Description of Operations:
List Classification Codes and Payroll: (one per line, seperated by comma. Ie: Code,$40,000)
Experience Mod (What is this?) (Who qualifies?)
Has this business been in operation for at least three years with prior workers compensation coverage?	Yes       No
Current Insurance Carrier
Is the loss ratio (avg annual losses / quotes premium) less than 40%	Yes       No
Hours of Operation
Do any employees ever work at heights exceeding 15 feet?	Yes       No
Are any employees involved in trucking or transportation operations?	Yes       No
Do employees handle hazardous materials?	Yes       No
Number of full-time employees?
Number of part-time employees?
Maximum number of employees working at one time at a location?
List other locations, if applicable:
If this is a new business, provide a description of the owner's prior experience managing or owning thist ype of business.(minimum of 2 years experience required)
Any WC losses in the last three years?	Yes       No
If yes, explain:

Once our agency has received your information we will contact you to prepare a quote.