Business Information Worksheet
A quote is just a fax away.
Business Name: _______________ Corporation __ Individual __ Other __ Address: ______________________________________________________ Current Carrier: _______________ Federal Employer ID No: ________ Number of Employees: __________ Expiration Date: __________________ Experience Mod: Full Time: ______ _______________ Part Time: _____
Building Value: ______________ Business Personal Property Value: ______ Contact Person:_________________ Phone Number: ____________Fax Number: ________E-Mail_____________ Class Code 8831 Description Physicians & Clerical Payroll $ ______
Fax this completed worksheet to 907-258-3105 for a quote. Or, if you would like, contact one of our Account Executives at 907-276-7667 or email: Mike Dennis CIC Paul Houston Mark Merritt Mark Swanson Allen Hanson (miked@chialaska.com) (paulh@ chialaska.com) (markm@ chialaska.com) (marks@ chialaska.com) (allenh@chialaska.com)