Additional Resources

Informational Brochure

Restaurant Questionnaire

Workers' Compensation Quote

Nevada Gaming and Hospitality Assocation

Restaurant Workers' Compensation

Please complete this form and click 'Submit' at the bottom.

Email *:
Formal Name of entity (Example: Abc, Inc. or Abc, LLC; etc.) *:
Street Address *:
Address Line 2:
City:
State / Province / Region:
Country:
Postal / Zip Code:
-
Name of principal contact (owner or manager) *:
Email for principal contact *:
Phone number for principal contact *:
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Fax number for principal contact *:
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Number of years in business *:
When do you need coverage? *:
Other:
Estimated Annual Payroll :
Remember to limit each employee to a cap of $36,000 *:
Are owners/officer to be included for work comp coverage? *:
Do you presently require pre-employment drug testing and post accident drug testing? *:
Do you currently have a written safety program? *:

 

Needed:
NCCI Experience Modification Worksheet (If you can't locate this, you can call NCCI at 1-800-622-4123, give them your FEIN and they'll send you a copy)

Loss runs for past 3 years plus current year (You can get these from your current insurance agent or current insurance company.)