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Broker Info

Company name

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Contact name

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Phone number

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Email

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Application

Insured Name

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1. What are the Renewal and Target Premiums?

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2. What other Worker's Compensation policy options is the insured considering: (providing other quotes may help us achieve the target)?

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3. Would the insured consider an alternative market for coverage provided it was competitive and beneficial to their business?

Examples 3a. PEO(Professional Employer Organization) - a PEO provides worker's comp with required payroll service under the FEIN of the PEO and considered a "co-employment" relationship.
3b. ASO(Admin Service Organization) -an ASO provides a standalone worker's comp policy with required payroll services under the client's FEIN

3. Would the insured consider an alternative market for coverage provided it was competitive and beneficial to their business?

4. What PEO and/or traditional markets has this risk been submitted to?

5. How does the insured currently process payroll?(In house ,ADP,Paychex,etc.)

5a. Are there any employees using Tax Id#'s as opposed to SS#'s

Yes

No

5b. Are any employees 1099's?

Yes

No

6. Are any of the employees union members?

Yes

No

7. Do you control this account or is it a prospect?

8. Reason for quote?(Non-renewed,shopping,mid-term change lapse in coverage etc.)

9. Is there a deadline for the quote to be received?Is there or will there be a lapse in coverage as of a certain date?What is that date?

10. Please list any other important criteria /considerations here.