Euclid Insurance

Insured Name:

Address:

City:

State:

Zip Code:

County:

Phone:

Contact Name:

Email:

Current Insurance Company:

Expiration Date:

Total Number of Employees:

Total payroll for each classification:

Read this first
You can either list employees individually and the worksheet below will calculate your total payroll, or list total payroll for each classification.

NOTE: Do not include payroll from sole proprietors, partners and corporate officers in this section (see below ):

	Name	Title	Code	Annual Remuneration
1

- OR -

Code	Description	Total Annual Remuneration
8601	Engineers/Architects/Surveyors - Consulting
Engineering/Architect/Surveyor: Not applicable when engaged in actual construction; not including underground surveying. Operations include consultations with clients; research on behalf of clients; site visits; and the compilation of information to make recommendations to clients.
8810 C	Administrative/Clerical
Administrative/Clerical: Applies to clerical and administrative employees. This classification applies even if the employee performs some duties outside of the office provided they do not involve direct supervision or physical labor and are related to their office duties (i.e. depositing funds at the bank, purchase of office supplies, pickup or delivery of mail, etc.)
8810 D	Drafting Employees/Graphic Designers
Drafting Employees/Graphic Designers: Individuals that have duties outside the office are not eligible for this classification.
8742	Sales
Sales: Outside sales activities such as visiting prospective clients to obtain their business. If any 8601 activities are performed by the employee, code 8601 is applied.
Other

ANNUAL REMUNERATION FOR SOLE PROPRIETORS, PARTNERS AND CORPORATE OFFICERS:

List sole proprietors, partners and corporate officers separately. Do not include payroll above:

	Name	Title	Annual Remuneration	Include or Exclude for Coverage
1				Include	Exclude

Employers Liability Limit (choose one):

Each Accident Bodily Injury by Accident
Policy Limit Bodily Injury by Disease
Each Employee Bodily Injury by Disease

$100,000/$500,000/$100,000 ( no additional premium charge applies to this option)

$500,000/$500,000/$500,000

$1,000,000/$1,000000/$1,000,000

Submitting this form does not bind the insurance company or agency to sell nor the applicant to purchase the insurance.