HAYES INSURANCE AGENCY

WE GET RESULTS!

Workers Compensation Questionnaire

This questionnaire is used to obtain information about your business operations. In most cases, we will need to obtain more information from you in order to provide you with an accurate quote.

The online questionnaires are a starting point and are very helpful in our quoting process. Please try to be as accurate as possible when answering these questions. Thank you.
First Name
Last Name
Company Name
Address Line 1
Address Line 2
City
State
Zip Code
Daytime Phone() -
Fax() -
E-mail Address
Please give a brief description of your business operation
Is this business incorporated
If incorporated, provide names of directors/officers and % of ownership
How many employees do you have (full and part time)
What is your ANNUAL payroll
What is your Federal Employer ID number (FEIN)
How long have you been in business
Questions, comments, or additional information
Please givve the name of the broker you are working with (if any)