JT KIA INSURANCE SERVICES...
Workmen's Compensation Insurance Quote Questioner.
Please answer all the questions below. Many companies offer obscure discounts so in order to provide you the most
completive proposal all this information is needed.
Full Name:
Company DBA:
Address, City,State, Zip.
Day time and Night time Telephone Number.
E-mail Address.
Federal Employer Tax ID
Form of Business, Corp.,Ind. Partnership, LLC
Please give me list of jobs which you have in
your business with class code and number
employees in each classification ,are they part
time or full time , also give me total annual
salary for each class.
Full name of owner, partners, officers, or
relatives to be included or excluded with their
date of birth ,title , relationships, ownership %,
duties, Included or Excluded
Has the business or any principal of the business declared bankruptcy in the last seven years. Yes or
No
Full name  and Social Security number of Owner, Officer, Wife, Husband, or Corp.
Full name  and Social Security number of Owner, Officer, Wife, Husband, or Corp.
Full name  and Social Security number of Owner, Officer, Wife, Husband, or Corp.
Please  Leave any comments or additional informations
Here.