Workers Compensation Insurance Quote Application
Effective Date
/
Month
/
Day
Year
Date
Business Name
Type of entity
Please Select
Sole Proprietorship
LLC
S-Corp
C-Corp
Partnership
Joint Venture
Non-profit
Contact name
First Name
Last Name
Contact phone number
Format: (000) 000-0000.
Email
example@example.com
Federal Employer's ID#
Type of Business
Mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Detailed Description of operations
Year this business started under the current ownership
Years of total overall experience the owner has in this business type
Losses past 3 years
Yes
No
Upload your '3 year loss runs'
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# of locations
Location address #1
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location address #2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location address #3
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location address #4
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
# of full-time employees location #1
# of part-time employees location #1
Estimated Total Annual Payroll Location #1
# of full-time employees location #2
# of part-time employees location #2
Estimated Total Annual Payroll Location #2
# of full-time employees location #3
# of part-time employees location #3
Estimated Total Annual Payroll Location #3
# of full-time employees location #4
# of part-time employees location #4
Estimated Total Annual Payroll Location #4
Experience Mod (if any, per policy)
Employee Type
Rows
Job Description
Annual Payroll Estimate
1
2
3
4
5
Officers / Partners / Owners Information to include or exclude from policy
Rows
Name
Title
Exclude from Coverage? Yes or No
% of ownership
1
2
3
Current insurance company
Current insurance company policy number
Current insurance company expiration date
-
Month
-
Day
Year
Date
Upload current workers compensation policy
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Submit
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