WORKERS COMPENSATION QUOTE FORM (Acord 130) Today's Date: QUOTE TAKER'S NAME: Email Address: What is your corporation's name: What is your federal ID number: What is your first name: What is your last name: Phone #: Fax #: What is your location address: City: State: Zip Code: Number of employees: Full time: Part time: Number of officers:   Name of Officers: Title % of share     1.     2.     3.     4.   Employee's payroll: Full time: Part time: Officer's payroll: Who is your current Insurance company: Expiration date: Current premium: $ Have you reported any claims in the past 3 years? Yes No If Yes, please describe loss:   NOTES