Harris and Harris Insurance Agency

"Serving All Your Commercial Insurance Needs"

Members

 

We are a member of the IIAT
(Independent Insurance Agents of Texas)

Harris and Harris Insurance Agency
15449 Northwest Boulevard
Coprus Christi, Texas
78410

 

Phone 361-387-0564

Request For Quote

windows

Payroll Information
(needed if you are requesting Workers Comp, Employee Leasing or General Liability)

# of Employees 

Please fill out the form to the best of your ability.  If you prefer not to take the time to fill in the information you may email us at customerservice@harrisandharrisins.com or simply give us a call at 800-572-7928.  We look forward to handling ALL of your Business Insurance needs!

Applicant

Legal Business Name
Address
City
State
Zip Code
E-mail
Phone
Bold = Required field
Contact name
Fax
Type of Entity
Officers/Owners name
FEIN#

Type of Coverage Requested
For Commercial property, please call our office at 800-572-7928

      Workers Comp

Employee Leasing
General Liability
Auto
Job Description
Annual Payroll
This section must be Clear, Complete & Consice

Years in Business
Description of Operations
Yes
No

Explain ALL YES answers

Has the company ever had a current or past employee file a charge of discrimination or any complaint against the company?

If yes, please explain
Does the applicant own, operate, or lease aircraft/watercraft?
Yes
No
If yes, please explain
Do operations involve storage, treating, discharging, applying, disposing, or transporting of hazardous materials?
Yes
No
If yes, please explain
Is any work performed underground or above 15 ft. (2 stories)?
Yes
No
If yes, please explain
Is any work performed on barges, vessels, docks, bridges, over water, longshoremen, or in a harbor facility?
Yes
No
If yes, please explain
Is applicant involved in any other business?
Yes
No
If yes, please explain
Are SUB-CONTRACTORS used?  If yes, please describe number of subs, percentage of subs and type of work by subs
Yes
No
If yes, please explain
Is work sublet without certificates of insurance?
Yes
No
If yes, please explain
Is a formal safety program in place?
Yes
No
If yes, please explain
Is any group transportation provided?
Yes
No
If yes, please explain
Are any employees under 18 years of age?
Yes
No
If yes, please explain
Are any employees part-time or seasonal?
Yes
No
If yes, please explain
Is there any volunteer or donated labor?
Yes
No
If yes, please explain
Do employees travel out of state?
Yes
No
If yes, please explain
Are pre-employment physicals required?
Yes
No
If yes, please explain
Does company bid or work on any government contracts?
Yes
No
If yes, please explain
Vehicle Information
Year/Make/Model
VIN
Approx. Value
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