Union Life & Casualty

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