Workers Compensation

Kelly & Co., Inc.

Request for Workers Comp Insurance Quote

PERSONAL INFORMATION

First Name:

Last Name:

Company Name:

Street Address

City

State

Michigan

Zip code

County

Contact Phone

Fax Number

Your E-mail address

CURRENT INSURANCE INFORMATION

Are you Currently Insured by Another Company?

YesNo

Insurance Carrier Name

Number of Years:

Type of Business:

Business Classification

Describe Prior Insurance Claims,

Claim History in Last 5 Years (Include all claims)

REQUESTED COVERAGES

Describe Business Operations in Detail:

Payroll Class #1:

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and describe payroll class:

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Payroll Class #2: (if none leave blank)

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and describe payroll class:

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Payroll Class #3 (if none leave blank:)

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and describe payroll class:

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COMMENTS OR QUESTIONS

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..............	Kelly & Co., Inc 2575 S Van Dyke Rd, Suite 102 Marlette, MI 48453	Marlette: 800.257.3735 989.635.2649 Fax: 989.635.3744	Kingston: 888.843.3388 989.683.2419 Fax: 989.683.3107	Kelly & Co., Inc 5951 State Street, Kingston, MI 48741