Atell Insurance
WORKMANS COMP. QUOTE REQUEST
Fields marked with an * are required.
Date*:
Company Name*:
Insured Name*:
DOB:
SSN#:
Type of Business:
Sole Proprietor
LLC
Inc.
Other
Date Business Started
 Built:
Mailing Address:
Business Address:
Business Phone*:
 Cell Phone:
Other Phone:
  
Years in Business
 Years Experience:
Fed Tax ID:
 Gross Annual Revenue
Nature of Business:
Job Description:
Full Time Annual Payroll:
 Part Time Annual Payroll
Is work subbed out: Yes  No
If yes type of work subbed out:
Prior Coverage:
Claims?
If prior coverage, loss runs will be needed
Notes:
A-Tell Insurance Agency

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