Pawnbrokers Workers Compensation | Pawn shops workers comp

Union Life & Casualty Insurance Agency
5225 N. Central Avenue, #110
Phoenix,AZ 85012
Phone (800) 545-5624 or Fax (602) 265-9763
Email: Laura @ PawnIns.com
Questions? Call Seth, David or Laura

Workers
Compensation
Quick Quote
Questionnaire

Fill in the online application below or download this PDF file to print and fax.

Date:
Named Insured:
Address:
Phone #:	Fax:
Contact Person:
Email Address:
Mailing Address
Federal Tax ID or Social Security #
Type Of Entity	Corporation Individual Partnership Other
# of year in business?
NCCI #
Prior or Current insurance carrier
Annual Premium
Please include a copy of your policy declaration page which indicates your payroll and current classification.
Has there been a lapse in coverage in the last 18 months?	Yes No
Is your coverage in force now?	Yes No
Average hourly wage of employees
Formal safety program	Yes No
Any prior losses in the last three years?	Yes No
If yes, describe or attach loss runs
# of full time employees:
# of part time employees:
Annual payroll estimate for all employees:
Exclude owners?	Yes No
If owners to be included - annual payroll
# of owners:
Name of all owners and date of birth
Any employees under 16 years old or owner under 60 years old?	Yes No

WorkersCompensationQuick QuoteQuestionnaire

Workers
Compensation
Quick Quote
Questionnaire