Keltner Insurance Inc
Your Local Independent Insurance Agency
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Privacy Statement
Workers Comp Questionaire
For Help Call 901-797-8665
Fields marked (
*
) are mandatory.
Agent Name
*
Agent Number
*
Agent PH #
*
Agent Fax #
Name of Business
*
Name of Owner
*
Type of Entity
*
Corporation
Individual
Other
Partnership
Federal Tax I.D. # or Social Security # ?
Address
*
Phone #
*
Fax #
E-Mail
*
Description/Nature of Business?
*
How many years in business?
OR - How much experience in this field?
Annual Payroll
*
Job Descriptions
How many Full Time employees?
*
How many Part Time employees?
*
Any Losses?
*
No
Yes
Owner/Officers
Name/Names
Duties
Include/Exclude for coverage
Birth Date
01
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12
01
02
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This form is for indication ONLY
To obtain a full quotation, we will require the following:
Copy of existing policy declarations page required
Claims/Loss History (5 years) with Insurance Company Loss Runs
Remarks
All items marked * must be answered to recieved a response!