Workers' Compensation
Insurance Application
Firm Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Contact
Title
Email
example@example.com
Website
Phone Number
Please enter a valid phone number.
Date firm commenced operations
-
Month
-
Day
Year
Date
Federal Tax ID #
Firm Type
Corporation
LLC/LLP
Partnership
Other
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Requested limits of insurance
$100k / $500k / $100k
$500k / $500k / $500k
$1 Million / $1 Million / $1 Million
Who is your current Insurance Company?
Carrier for Workers' Compensation
Current Policy Period
Projected Payroll and # of Employees
Type a question
Rows
Projected Payroll
# of Employees
8603 Draftsmen
8603 Clerical
8601 Engineer / Architect / Consultant
8602 Surveyors
Others: (explain below)
Others: (from above)
Describe role
Partners, Officers & Individual Owners to be included or excluded from coverage:
Rows
Name
Title
% Ownership
Duties
Payroll
Excluded?
#1
#2
#3
#4
#5
If additional space is needed, please attach a list of Owners/ Principals with information above:
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Additional Employment Information
Nature of Business/Description of Operation:
Do you own, operate or lease aircraft/watercraft?
Yes
No
If yes, please explain.
Does your operation involve storing, treating, discarding, applying, disposing, or transporting of hazardous materials?
Yes
No
If yes, please explain.
Do you own, operate or lease aircraft/watercraft?
Yes
No
If yes, please explain.
Any work performed underground or above 15 feet?
Yes
No
If yes, please explain.
Any work performed on barges, vessels, docks and bridges over water?
Yes
No
If yes, please explain.
Any part time or seasonal employees?
Yes
No
If yes, please explain.
Is there any volunteer or donated labor?
Yes
No
If yes, please explain.
Are there any employees with physical handicaps?
Yes
No
If yes, please explain.
Are athletic teams sponsored?
Yes
No
If yes, please explain.
Does any employee travel out of state?
Yes
No
If yes, please explain.
Does any employee travel out of country?
Yes
No
If yes, please explain.
Any prior Worker's Comp coverage declined/cancelled/non-renewed in the last three years?
Yes
No
If yes, please explain.
Is an employee health plan provided?
Yes
No
If yes, please explain.
Do any employees predominantly work at home?
Yes
No
If yes, please explain.
Any Worker's Compensation losses in the past three years?
Yes
No
If yes, please explain.
Are Sub-Contractors used?
Yes
No
If yes, please explain.
Any work subcontracted without a certificate of insurance provided by the subcontractor?
Yes
No
If yes, please explain.
Any employees under 16 or over 60 years of age?
Yes
No
If yes, please explain.
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Applicant's Name
Title
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: