Workers Compensation Quote - Monteleone Insurance

service@monteleoneins.com | 631-544-4000

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Worker’s Compensation Policy – Fact Finder

The following information requested is strictly to find and determine the most comprehensive approach to your insurance needs, and overall strategy.

Please answer all to the best of your ability. If there is no answer, please write N/A or leave blank in the space provided.

Any questions or concerns: broeder@monteleoneins.com or 631-544-4000

Contact Information

Your Name *

Phone Number *

Email *

Current Policy Information

Kindly upload any existing policy information to equally compare coverages for new quotes.

Attach Your Existing Policy (If One Exists)

Drag & Drop Files, Choose Files to Upload

General Company Information

Company Name & DBA *

Year Business Founded: *

Physical address(s) *

Mailing address *

FEIN # *

Complete Description Of Operations: *

Each Owners' Information

Full Name *

% Of Ownership: *

Include or Exclude Coverage: *

Annual Salary *

Add 2nd Owner

Add Another Owner

Full Name *

% Of Ownership: *

Include or Exclude Coverage: *

Annual Salary *

Add 3rd Owner

Add Another Owner

Full Name *

% Of Ownership: *

Include or Exclude Coverage: *

Annual Salary *

Add 4th Owner

Add Another Owner

Full Name *

% Of Ownership: *

Include or Exclude Coverage: *

Annual Salary *

Add 5th Owner

Add Another Owner

Full Name *

% Of Ownership: *

Include or Exclude Coverage: *

Annual Salary *

Location(s) Information

Per Location, Per Class Code Please List:
a. Location:

i. Class Code Description (Ex: Clerical, Driver, Carpenter etc.):
ii. # Of Employees In This Class Code (Specify PT & FT):
iii. Total Combined Payroll/Remuneration In Class Code:

Location Information *

New York State Disability & Paid Family Leave

How Many FT Employees? *

How Many PT Employees? *

How Many Male Employees? *

How Many Female Employees? *

How Many Employees (not including Owners) Earn Over $91,373.88 annually? *

Total Combined Annual Payroll Amount To All Employees Earning Less Than $91,373.88 annually? *

Would Owner(s) Like To Be Covered? *

Yes
No

Carrier Questions

Do the owners want to be included in this workers compensation quote? Note owners may be covered under their own health insurance. *

Yes
No

Does applicant own, operate or lease aircraft/watercraft? *

Yes
No

Past or present operations in handling hazardous materials? *

Yes
No

Any Work performed underground or above 15 feet? *

Yes
No

Any work perfomred on barges, vessels, docks, bridge over water? *

Yes
No

Is applicant engaged in any other type of business? *

Yes
No

Are sub-contractors used? *

Yes
No

Any work sublet without certificates of insurance? *

Yes
No

Is a written safety program in operation? *

Yes
No

Any group transportation provided? *

Yes
No

Any employees under 16 or over 60 years of age? *

Yes
No

Any seasonal employees? *

Yes
No

Is there volunteer or donated labor? *

Yes
No

Are there any employees with physical handicaps? *

Yes
No

Do employees travel out of state? *

Yes
No

Are athletic teams sponsored? *

Yes
No

Are physicals required after offers of employment are made? *

Yes
No

Any prior coverage declined/cancelled/non-renewed in the last 3 years? *

Yes
No

Are employee health plans provided? *

Yes
No

Do any employees work for other businesses or subsidiaries? *

Yes
No

Do you lease employees to or from other employers? *

Yes
No

Do employees predominantly work at home? *

Yes
No

Are there tax liens or bankruptcy within the last 5 years? *

Yes
No

Are there any undisputed and upaid workers compensation premiums due from you? *

Yes
No

Questions/Notes/Comments

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Monteleone Insurance

Hauppauge, NY

service@monteleoneins.com

Mo,Tu,We,Th,Fr 8:00 am – 5:00 pm

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Contact Our Office

Monteleone Insurance

Hauppauge, NY

service@monteleoneins.com

Mo,Tu,We,Th,Fr 8:00 am – 5:00 pm
Sat & Sun by call or Appointment

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