Business Owners and Workers Comp
Name
Name of Business or Entity
Contact Number
Limits Requested
1m/2m
2m/4m
Other
Building Sq. Ft.
# of Floors in building
Year Built
Is there an alarm system?
Yes
No
Construction Type
Masonry Non-Combustible
Joisted Masonry
Fire Resistive
Veneer
Wood Frame
Other/not listed
Year business started
Any Claims in the Past 5 years?
Yes
No
Number of Employees
Workers Comp Limits Desired
100/500/100
500/500/500
1m/1m/1m
Number of Physicians
Physicians Salary
Number of Clerical Employees
Clerical Employees Salary
Are You a UOP member?
Yes
No