March 16, 2007 - Arrowhead General Insurance Agency, Inc.
ARROWHEAD Workers’ Compensation Program
Small Workers’ Compensation Accounts (under $15,000) Questionnaire
|Insured Name: | |
|Total Annual Payrolls |Total Annual Premium |
|Current Year: |Current Year: |
|Prior Year: |Prior Year: |
|Prior Year: |Prior Year: |
|New Venture: No Yes If yes, owner resume required. |
|Operations and Benefits |
|Hours of Operation: to |# of Shifts: |Driving exposure No Yes Delivery No Yes |
|Group Med. or Employer Contribution No Yes |Radius of operations |
|% Enrolled: % paid by employer: |1-4 1-5 1-6 ................
................
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