Welcome to Vicencia & Buckley Insurance.

Workers Compensation - Request for Proposal

Employer Name:

Corporation	Partnership	Sole Proprietor	Other


FEIN:
State ID #:

Address 1:
Address 2:
City:	State:	Zip:

Phone:	FAX Number:
Email Address:


Payroll Schedule:
Class Code	Duties #	Employees FT/PT	Est. Annual Payroll


Ownership Schedule:
Name	Title	% Ownership	Duties	Incl. or Excl.	Annual Payroll


Prior Carrier Information:
Year	Policy #	Carrier	Annual Premium	Exp. Mod.	# Claims	Paid	Reserve


Description of Operations:


Do you have a written Safety Plan?		Yes		No

Do you have an employee handbook?		Yes		No

License #: 0578496
Copyright Vicencia & Buckley Insurances Services Inc.

The information herein is for illustration purposes only and is designed as a general description of coverage's. Coverage will be determined by the actual policy language.

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