118 W. Greeley Ave.
Tribune, Kansas 67879
Phone: 620-376-4239
Fax: 620-376-2443
Email To: info@firsttribuneinsurance.com

Workers Compensation Insurance Quote Form

First & Last Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
Fax:  

Current Insurance Information
Insurance Company Name:  
Any losses in last 3 years?:  
# of claims:  
Claim amt. pd $:  
Premium Amount:  
Policy Exp. Date:  
MOD Factor:  
Policy #:  
Describe the type of Coverage you currently have:  

Prior Carrier Info
Insurance Company Name:  
# of claims:  
Claim amt. pd $:  
Premium Amount:  
How many years with:  
MOD Factor:  
Policy #:  

About Your Business
# of Full-time:  
# of Part-time:  
Owner's Name:  
Fed Tax ID:  
License Type:  
Yrs in Business:  
License #:  
# of locations:  
Annual Gross Sales:  
Square Footage:  
Est payroll / mo.:  
Type of Business:  
Please describe your business here:  

Owners / Partner / Officers
Name
Date of Birth
Title
Ownership %

Payroll Information
Class Codes
Employee Duties
Annual Payroll $
Hourly Wage $

General Information
Do you offer safety programs?
Do offer health benefits to majority of employees?  
Do employ any minors (under 18)?  
Is operation all/part of existing business that was purchased/acq.?
Do you use subcontractors?  
Use any equipment that bends/shapes/forms?  
Are athletic teams sponsored?  
Been a lapse in coverage during past 12 months?  
Any work above 15 feet?  
Had a bankruptcy in past 7 years?  
Are a member of any trade organizations?  

Additional Information:
Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.