Tuttle & Traina Insurance Agency, Inc.

Surety & Insurance Services

Richard C. Traina

William B. Tuttle

Thomas D. Moylan

Raoul Cormier
44 Main Street, Post Office Box 489, Sterling, MA 01564
Phone: (978) 422-7700    Fax: (978) 422-8106

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WORKERS' COMPENSATION QUOTES

We need to know your company's experience modification and ARAP modifier so we can give you an accurate quote on your workers' compensation. If you do not have a copy of your most current Experience Modification Calculation Worksheet, you can request one from your current insurance agency of print, complete and fax to us our form: Insured's Authorization to Release Experience Modification Calculation Worksheet.  (Click here for a copy in MSWORD.)

Please complete this form and click the "submit" button below. We will contact you ASAP.

Name of Company:  

Mailing Address:

Contact:        Telephone No:  

E-Mail:                                     Fax No. :       

Federal ID Number:    Bureau ID Number: 

 Experience Modification:   Current Policy Expiration Date:


1. List all states in which operations are currently taking place:               

Loc

State Name

Location Address

No. of Employees

 #1

 

 

 #2

 

 

 #3

 

 
#4  

 
#5  

 

2. Payrolls, class of work, etc.:

Location No.

Class Code

Description of Work/Operations

Payroll Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. List all claims in the last 5 years:  Check here to warrant there are no Workers' Compensation claims in the last 5 years.

Year Company Description of Claim Amt. Paid Amt. Reserved Claim Closed