* =Required Fields

* Business Name
Premises Address
City
State
Zip
Contact Name
* Email
Phone
Fax
Years in Business

About Your Illinois Business:

Federal Employer's ID #
Description of Operations or SIC code
Number of full-time employees
Number of part-time employees
Number of locations
Estimated Annual Payroll $
Experience Mod (if any, per policy)

Select all that apply to your Illinois business:

Operate or lease aircraft/watercraft Work Underground
Work above 15 feet Require out of state travel
Use Subcontractors Delivery Service
Pre-employment physicals Offer safety incentive programs
Store, treat, dispose, or transport hazardour waste
Work on vessels, docks, or bridges over water
Other

Recent Insurance Information:

Current Insurance Company
Policy #
Expiration Date:
(mm/dd/yyyy)
Losses past 3 years Yes No
Description of losses or loss runs

What types of coverages do you currently have: Commercial Auto
Commercial Liability
Commercial Property
Workers Comp
Group Health
Group Life
Group Disability
Group Long Term Care
Other

Illinois Employee Information

Employee Classification Code Yearly Payroll Estimate
1 $
2 $
3 $
4 $
5 $

Officers / Partners / Owners Information:

Principal Name Title Include
1 Yes No
2 Yes No
3 Yes No

Additional Information or Comments

* Enter Security Code