Mathes Insurance Group - Workers Compensation Quotation Form

Yes No

Construction Type: Frame Concrete Metal

# Stories

#Basements

Sq. Footage

Burglar Alarm:
Yes No

Building Value: $

Contents: $

Other Property ( Specify)

Property / Premises Information 3

Street Address:
Owner Tenant	Year Built:	% Occupied
Sprinklers?: Yes No	Construction Type: Frame Concrete Metal
# Stories	#Basements	Sq. Footage
Burglar Alarm: Yes No	Building Value: $	Contents: $
Other Property ( Specify)

Liability

Class of Business:
Contractor / Building Trades	Contractor / Professional Services	Retail
Professional Office	Truckers	Other

Annual Gross Sales (before taxes)

# of employees:

Annualized Payroll:

Cost of any Subcontracted Work:

Limits Requested: $300,000 $500,000 $1,000,000 $2,000,000

Describe any claims you've had in the past 5 years:

Federal Information:

Federal I.D. Number

Current Experience Modification:

Rating Information:

Classification Description (By Employee Group)	Annual Payroll (By Group)

Names of Owners / Corporate Officers:

Additional Comments:

Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this
Workers Compensation Insurance Quote Form.
One of our representatives will respond to your
submission as soon as possible!

Mathes Insurance Group 120 W. State Street Mason City, Iowa 50401	Phone: 515-423-4663 Toll Free: 877-421-4663
E-Mail: rickmathes@rickmathes.com