United State Longshore and Harbor Workers Compensation (USL&H) Insurance, Marine Employers Liability or Jones Act Insurance (MEL) and State Workers Compensation Insurance Quote
* Name
*Company Name
Website:
* Email Address:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Best Time To Contact:
Contact By:

Current Policy Information
Workers Compensation Insurance Company:
Workers Compensation Premium:
Workers Compensation Expiration Date:
Are You Currently Recieving a Workers Compensation Dividend?  
Have you already reviewed your NCCI Experience Modification Factor?  

       Workers Compensation Undewriting
  Employee Duties/ Classification Class Code (if Known) Number of Employees Annual Payroll USL&H MEL
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Additional Underwriting Questions
Have you been cancelled, non-renewed oe declined for insurancein the past 3 years?
Has the applicant had a foreclosure, repossession, bankruptcy, judgment or lien in the past 5 years?
Has the applicant been involved in any lawsuits, or had any judgements or leins against them in the past 5 years?
Are any other business operations owned by the applicant, or any owners of the applicant company?
Do you have a formal safety program?
Do you check employees' Motor Vehicle Records prior to hire?
Would you like ALC Risk to quote any other lines of insurance for you?
What other lines of insurance would you like a quote for?


Additional Information
Please list additional vehicles, drivers or other pertinent information to help expidite the underwriting process.
 

 

Please call 786-664-RISK (7475) or visit www.alcrisk.com

E-mail: acohn@alcrisk.com