Skip to content

Facebook Instagram LinkedIn

Call Today (816) 380-3800 | Request A Quote

Search for:

About
Insurance Services
Make a Payment
Contact

Search for:

About
Insurance Services
Make a Payment
Contact

Search for:

Request a Quote for Workers Compensation Insurancecpskdeveloper2019-05-15T13:06:16-05:00

REQUEST A WORKERS COMPENSATION QUOTE

Name *

First

Last

Business Name *

Email *

Cell Phone *

Business Phone

Website

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Policy Effective Date Requested *

Entity Type *

Individual
Coporation
LLC
Partnership
Other

EIN or or SSN: *

Year Business Started *

Years of Experience in this Type of Business *

Description of Business *

Tell Us About Your Employees

# of Full Time Employees *

# of Part Time Employees *

Total # of Locations *

Experience MOD (if any)

Employee Information (Job descriptions with their class code, # of employees with that description, and their annual payroll estimate)

Officers/Partners/Owners Information (Names with each person's title, Class Code, and whether they should be included in coverage)

Are Subcontractors/Independent Contractors Used? *

Yes
No

If yes, do you require that they provide you with a Certificate of Insurance as evidence of their own insurance?

Yes
No

Total Annual Cost for Subcontractors/Independent Contractors (in $ amount) (copy)

Any work performed underground or above 15 feet? *

Yes
No

Any work performed on docks, barges, vessels, bridge over water? *

Yes
No

Do employees travel out of state? *

Yes
No

If yes, where?

Any prior coverage declined, cancelled or non-renewed in past 3 years? *

Yes
No

Is applicant engaged or have ownership in any other type of business? *

Yes
No

Does applicant own, operate or lease any watercraft or aircraft? *

Yes
No

Do you own the building in which you operate your business from? *

Yes
No

Square footage occupied by your business: *

Prior Insurance (Include each company with the policy number, # of claims, and the amount paid on each claim)

Please provide 5 years valued Loss Runs at your earliest convenience. If this is a new, or relatively new business venture, please provide Loss Runs for the amount of years that you have had coverage.

By typing my name in the field below, I attest that the above information is true and correct.

Today's Date

Email

Contact Us

(816) 380-3800

2765 Cantrell Rd.
Harrisonville, MO 64701

We are located inside the Mill-Walk Mall.

JOHN SOUTHARD
john@cpskinsurance.com

RANDY MAY
randy@cpskinsurance.com

AMANDA TABER
amanda@cpskinsurance.com

CHANDRA TURNER
chandra@cpskinsurance.com

SUMMER SMITH
summer@cpskinsurance.com

REQUEST A QUOTE

INSURANCE SERVICES

2765 Cantrell Rd.
Harrisonville, MO 64701

Phone: (816) 380-3800

Copyright 2019 CPSK Insurance Services Inc. | All Rights Reserved