Don Evans Insurance Agency

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WORKMANS COMPENSATION QUOTE for our TIMBER CLIENTS
We provide insurance coverage for Minnesota and Wisconsin only

Non timber accounts should contact us by phone at 218-326-0563.

Timber accounts of almost any type can be written under the work-comp programs that we have available in our agency. In order to provide an accurate quote we would ask that you please provide us with the following information at the time of quoting. Information necessary to the quoting process may be collected from consumer reporting agencies, inspection services and motor vehicle departments. This information is available to the insurance companies who provide the quotes. *Required infomation

Name:	*
Address:
City:
State:
ZIP:
Home Phone:	*
Email:	*
Work Phone:
Cell Phone:
Business Name:	*
Years In Business:
Federal Tax ID Number:
Social Security Number:
Minnesota Employers ID:
Type Of Business Entity: Sole Proprietorship Partnership Corporation Limited Liability Corporation

A breakdown of your payroll by work-classification will be required. If you are a logger the following classifications might be applicable to your operation.
Annual Payroll $ Logging or Lumbering. Class code 2702 Annual Payroll $ Local Trucking. Class code 7228 Annual Payroll $ Excavation. Class code 6217 Annual Payroll $ Clerical. Class code 8810 Annual Payroll $ Truck Maintenance. Class code 8395
Do you have individuals that you want excluded from coverage? These would include partners, officers, and relatives. If so, please list them here and make sure that they are not included in the payroll figures listed above. Also be aware that any work-comp related loss suffered by any of these excluded individual will not be covered by the work-comp policy.

Please provide us with your current Experience Modification Factor:
Do you have current loss runs or claims experience reports from your current insurer? Yes No We can provide a quote based on your verbal disclosure of any prior claims but we cannot guarantee the rate or bind the coverage until we have documents indicating your loss experience for the three prior years.
What is the name, policy number and date of renewal of your current insurance company?
Do you have sub-contractors working for you? Yes No If you have subs you will need to obtain certificates of insurance from them in order to verify that they have their own coverage in-force and to eliminate the possibility that they could be included in your payroll totals and subsequent premium calculations.
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