Do I Qualify for IntelliComp®? Do I Qualify for IntelliComp®?
Slaton Insurance Do I Qualify Form
Our intense level of involvement and commitment to reducing our members' workers' compensation costs requires us to be selective about whom we take on as IntelliComp® participants. May we ask a few questions to see if your firm may be a candidate?
First Name Last Name
Company Name
Street Address
City/Town State
Zip
Phone Email address
 
How many current employees?
 
Please estimate your turnover ratio:
 
Please estimate your annual workers' comp premium:
 
In the past three years has your experience modifier increased by:
 
In the past three years do you feel that you may have been a victim of a fraudulent claim, or that a carrier paid more than they should have by settling a claim for higher than you felt was justified?
 
If provided the knowledge and proper supporting resources, are you an employer who is committed to reducing your long-term cost of workers' comp insurance?
 
Please estimate your annual payroll:
$
 
Effective Date of Policy: (mm-dd-yyyy)
 
Current Carrier:
 
Loss Experience:
 
An IntelliComp® representative will contact you within 24 hours, and if your business qualifies, we will set up an appointment to discuss workers' compensation. Thank you for your response and we look forward to helping you dramatically reduce your long-term cost of insurance.
 



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