Workers' Compensation Insurance

Workers' compensation is a mandatory type of business insurance that provides employees who become injured or ill while on the job with medical coverage and income replacement. It also protects companies from being sued by employees for the workplace conditions that caused such an injury or illness.

First & Last Name:

Business License #:

Telephone:

Email Address:

How did you hear about Pike Insurance?

What size T-Shirt do you wear?

What size Hat do you wear?

Company Name:

Years in Business:

Mailing Address:

City:

State:

Zip Code:

Company Telephone:

Company Fax:

Projected Annual Payroll 2007 - 2008:

Class Code	Hourly Wage	Annual Payroll	# of Employees	FT / PT

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Current Expiration Date:

Do you have a Formal Safety Program
in place?

YES ( If YES, briefly describe ) NO

Have you had any Claims?

YES ( If YES, briefly describe ) NO

What is your X-Mod?

Federal ID Number / Social Security Number:

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