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Broker Info

Company name

Contact name

Phone number


1. What are the Renewal and Target Premiums?

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

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

  • 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.

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.

11. Please attach the following:

  • a. Accord-130 with employee count by class code.
  • b. 3-5 years of loss dated within the last 60 days.
  • c. Mod worksheet (if available)
  • d. Supplemental(if applicable)
  • e. Explanation for losses of $25,000 or above and describe measures implemented to prevent recurrence of same.

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Please check to be sure 130 has employee count by class code and loss runs are dated within 60 days.