American PEO Insurers - Insurance for PEO - Workers' Compensation for PEO

Request a Quote

Please complete our PEO Indication Form below to request a quote. One of our representatives will contact you shortly.

* Required Fields

Contact Information

* Full Name:
Title:
* Phone:	10 digit phone number
Fax:	10 digit phone number
* Email:

Business Information

* Company name:

* Address:

primary address of company

* City:

* State:

* Zip code:

What state(s) do you currently do business in:

Number of client companies:

Number of staff employees:
(this year)

Full time:
Part time:
Annual payroll:

Number of leased employees:
(this year)

Full time:
Part time:
Annual payroll:

Gross annual revenues:

Current Insurance Information

Please provide information on your current insurer for the last 3-5 years and the coverage provided:

Dates of coverage	Insurance company	EPL limits	General liability limits	Professional liability limits	Deductible	Premium

Has any Director, Officer, Manager, Supervisory Employee or Partner knowledge of any circumstances, which could reasonably give rise to a claim or foresee that a claim may be brought OR have any previous claims been brought against you in the past 5 years?

YesNo

Loss History

Please provide a company loss history for the last 5 years in the table below.

Date of claim	Nature of claim	Defense amount	Indemnity	Outstanding reserves	Open/Closed

Layoff History

Have you had any lay offs in the last 12 months

Yes

Do you anticipate any lay offs in the next 12 months

Yes

If yes, please provide details below including date of layoff, # of employees, job category, and the manner in which layoffs were/will be conducted and any terms of severance

Human Resource Procedures Have you adopted and implemented:

APII provides Insurance for PEO, workers' compensation for PEO, Insurance for employee leasing, Staffing insurance, and temporary staffing insurance.