IMPORTANT NOTICE

  1. This workers compensation quote request applies only to the state of Oregon. Do not fill out this form if your employees do not work in Oregon.
  2. Most insurance companies, including workers compensation carriers, may use information from you and other sources which pertains to the ability of you or your business to meet financial obligations. By submitting this quote request, you are giving permission to the possible access and review of your credit history and credit rating. This authorization extends to Beaverton-Tigard Insurance and to any workers compensation carrier that it may contact for the purpose of obtaining this coverage for you and/or your business. This authorization is to remain in force until you choose to rescind it in writing.
  3. No coverage will be started by submitting this form. Coverage may be placed in force only after you decide to purchase it from us, and then after you pay the initial premium.
  4. Submitting the following quote request constitutes your agreement with the above statements. We will contact you within two business days after we receive your request. If you have questions concerning this notice or about the following form, please call us at 503-620-0230 or toll-free 1-888-620-0230.

 

Workers Compensation Quote Request
  1. Your Full Name
    Please type your full name.
  2. Email address
    Please type your valid Email Address.
  3. Phone number
    Please type your full name.
  4. Fax number
    Please enter your Fax Number.
  5. Business entity
    Please select an option.
  6. Name of business
    Please enter your Business Name.
  7. Doing business as (DBA)
    Please enter your DBA Moniker.
  8. Business Website, if any
    Invalid Input
  9. Federal employer tax ID number
    Please enter your Federal employer tax ID number.
  10. Year business started
    Please enter the Year Your Business Started.
  11. How many years experience
    Please enter your Years of Experience.
  12. Street address
    Please enter your Street address.
  13. City
    Please enter your City.
  14. State
    Please enter your State.
  15. Zip code
    Please enter your Zip Code.
  16. Mailing Address, if different
    Invalid Input
  17. Addresses of other business locations
    Invalid Input
  18. Date your current coverage began
    Please enter the Date Your Current Coverage Began.
  19. Name of current work comp company
    Please enter the Name of Your Current Work Comp Company.
  20. Date you want coverage to begin
    Invalid Input
  21. If previous coverage canceled or non-renewed, explain why
    Invalid Input
  22. Business description (Explain what your business does)
    Invalid Input
  23. Names of all owners and percentage of ownership
    Invalid Input
  24. Number of full time employees
    Invalid Input
  25. Number of part time employees
    Invalid Input
  26. Estimated annual payroll
    Invalid Input
  27. If more than one class of employees, provide class description, number of employees and payroll
    Invalid Input
  28. How many years experience in managing employees?
    Invalid Input
  29. Estimated annual gross receipts
    Invalid Input
  30. Any claims or losses in past 5 years? Describe
    Invalid Input
  31. Describe the main hazards of your business
    Invalid Input
  32. Describe procedures taken to prevent injuries to employees
    Invalid Input
  33. Experience modification factor, if any
    Invalid Input
  34. If your employees work outside of Oregon, name other states they work in and payrolls.
    Invalid Input
  35. The next 7 questions are for contracting businesses only. Non-contracting businesses do not need to answer the next 7 questions.
  36. Contractor registration number
  37. Percent of work sub-contracted
    Invalid Input
  38. Estimated annual sub-costs
    Invalid Input
  39. Percentage of residential work
    Invalid Input
  40. Percentage of commercial work
    Invalid Input
  41. Percentage of work on new construction
    Invalid Input
  42. Percentage of work on existing construction
    Invalid Input
  43. Additional information or comments.
    Invalid Input
  44. Re-type the Security Field numbers in the box
  45. Security Field
    Security Field
    Invalid Input
  46. To save a copy of this form, please Print before Submitting.
  47. Submit
      

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Questions?

If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.