WORKER'S COMPENSATION LOGO

Auten, Inc. Insurance On-Line Free Rate Quote Form
Please call if you have any questions (800-749-6122).
The information page of your current policy has most of the required information.
1. Your Name
1a. Company Name (if different)
2. Physical Address
2a. Mail Address (if Different from #2)
3. City, State & Zip Code
4. County
5. Telephone Number
6. FAX Number
7. E-Mail
8. Nature of Business
8a. Number of Years in Current Business?
8b. Number of Years of Experience in Occupation?
9. Out of State Locations
10. Complete Description of Kind(s) of Work/Business
You Do. (Call if you have any questions). 		A.
B.
C.
D.
E.
11. Payrolls In Each Class Code: (Call If You Have Any Questions)
A. Class Code: Payroll: $ No. of Employees In Code:
SPACER GIFB. Class Code: Payroll: $ No. of Employees In Code:
SPACER GIFC. Class Code: Payroll: $ No. of Employees In Code:
SPACER GIFD. Class Code: Payroll: $ No. of Employees In Code:
SPACER GIFE. Class Code: Payroll: $ No. of Employees In Code:
12. Employers Liability Limits $500,000 $1,000,000
13. Do You Have A Debit Or Credit Modification? No: Yes:

If Yes, Your Modification?
14. Federal Employer Identification Number (FEIN)
15. Type of Entity
(partnership, proprietorship, Corporation, other) ? 		Partnership:
Proprietorship:
Corporation:
Other Type Entity:
15a. Are officers/owners insured? No: Yes:
16. Are you in the construction/contracting business? No: Yes:
16a. If Yes to #16, are subcontractors used? No: Yes:
16b. If Yes to #16a, what percent are insured? Percent Subcontractors Are Uninsured:
16c. If Yes to #16a, what percent are uninsured? Percent Subcontractors Are Uninsured:
17. Any workers' compensation related injuries or losses? If Yes, Please Explain:
18. Have you had prior workers' compensation coverage? No: Yes:
18a. Company now insuring?
18b. Expiration Date of Current Insurance?
19. How would you like to receive your quote? E-Mail:
Fax:
U.S.Postal Service:
Phone:

Depending on payrolls, we may need past claims' information to provide you our best bid.
We Hope to hear from you soon! Thank you.


20. Company Use Only (000006)
Date: Time:
Deposit: Monthly Payments:
Other:

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