September 9, 2010 i
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Information Disclosure
In order to provide you with an accurate quote from one of our insurance carriers, we may need to collect information from consumer reporting agencies, such as driving record, claims, and credit history reports.
Please read Southern Indiana Insurance's Privacy Policy.

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Contact Information
Your Name:
 Company Name
Personal Address
 Company Address (if different from personal address)
City
 City
State Zip
 State Zip
Telephone Number
 Fax Number
E-Mail
 Description of Business
Payrolls In Each Class Code: (Call 94108400 if you have any questions)
4 digit Class Code:  Payroll: $ No. of Employees In Code:
4 digit Class Code:  Payroll: $ No. of Employees In Code:
4 digit Class Code:  Payroll: $ No. of Employees In Code:
4 digit Class Code:  Payroll: $ No. of Employees In Code:
4 digit Class Code:  Payroll: $ No. of Employees In Code:

Owner(s)/Officer(s) Name(s)

Social Security #

Included/Excluded 

% of ownership
INCLUDED EXCLUDED %
INCLUDED EXCLUDED %
INCLUDED EXCLUDED %
INCLUDED EXCLUDED %

Workers Compensation Claims/Losses Information:
Policy Year Estimated Dollar amount
Estimated # of claims
2004-Present
2003-2004
2002-2003
2001-2002
2000-2001
1999-2000
Additional Information
NCCI Experience Modification (if known)
 		Federal Employer Identification Number (FEIN)
Type of Entity
Partnership Proprietorship Corporation Other:
Are you in the construction/contracting business?
No Yes

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