Workers Compensation Quote Request

IMPORTANT NOTICE

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.
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.
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.
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.

Your Full Name

Please type your full name.
Email address

Please type your valid Email Address.
Phone number

Please type your full name.
Fax number

Please enter your Fax Number.
Business entity

Please select an option.
Name of business

Please enter your Business Name.
Doing business as (DBA)

Please enter your DBA Moniker.
Business Website, if any

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Federal employer tax ID number

Please enter your Federal employer tax ID number.
Year business started

Please enter the Year Your Business Started.
How many years experience

Please enter your Years of Experience.
Street address

Please enter your Street address.
City

Please enter your City.
State

Please enter your State.
Zip code

Please enter your Zip Code.
Mailing Address, if different

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Addresses of other business locations

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Date your current coverage began

Please enter the Date Your Current Coverage Began.
Name of current work comp company

Please enter the Name of Your Current Work Comp Company.
Date you want coverage to begin

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If previous coverage canceled or non-renewed, explain why

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Business description (Explain what your business does)

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Names of all owners and percentage of ownership

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Number of full time employees

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Number of part time employees

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Estimated annual payroll

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If more than one class of employees, provide class description, number of employees and payroll

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How many years experience in managing employees?

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Estimated annual gross receipts

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Any claims or losses in past 5 years? Describe

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Describe the main hazards of your business

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Describe procedures taken to prevent injuries to employees

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Experience modification factor, if any

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If your employees work outside of Oregon, name other states they work in and payrolls.

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The next 7 questions are for contracting businesses only. Non-contracting businesses do not need to answer the next 7 questions.
Contractor registration number
Percent of work sub-contracted

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Estimated annual sub-costs

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Percentage of residential work

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Percentage of commercial work

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Percentage of work on new construction

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Percentage of work on existing construction

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Additional information or comments.

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Re-type the Security Field numbers in the box
Security Field

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