General Liability + Workers Compensation

General Liability + Workers Compensation
YesNo
EZLynx URL*
Company Name*
Owner Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Yes, it's correctNo, we need to update.
Describe the changes:
YesNo
What is the reason for the re-quote?*
General LiabilityWorkers Compensation
Please analyze the CLASS CODES on the current policy. Do we need to make any adjustments? *
Please analyze the ANNUAL SALES on the current policy. Do we need to make any adjustments?*
Please analyze the EMPLOYEE PAYROLL on the current policy. Do we need to make any adjustments?*
Please analyze the INSURED SUB PAYROLL on the current policy. Do we need to make any adjustments?*

Rating Information

Your quote will be based on the following information. Try to answer as accurately as possible.
Estimated Annual Revenue/Gross Sales*
This is the TOTAL amount received for your services before taxes and expenses.
Yes, employees onlyYes, subcontractors onlyYes, employees and subcontractorsNo, I work alone.
How many employees do you have?*
What do you estimate the total annual payroll to be for employees?*
For the chance of getting you the best rate, we recommend breaking the payroll down specifically into class codes, because each class code is rated differently. Also, if one of the classes selected above is done ONLY by insured subs, you can note it here. *
What do you estimate the total annual payroll to be for insured subcontractors?*
Yes, I keep copies of COI

Workers Compensation

Workers Compensation/Employers Liability covers employee work related injuries and illnesses, as well as lawsuits against your business as the employer. You may choose to include yourself however this will be an additional cost.
YesNo
I currently have Workers Compensation insuranceI had coverage but it was cancelled/expiredI have never had Workers Compensation insurance
What is/was the expiration date of your current/prior policy?*
What insurance carrier?*
How long were you insured with them?*
Yes, I have had a loss or claim.No, I have had no losses or claims.
Please explain in detail about the loss, including the date and amount paid by the insurance company. *
Minimum coverage/Ghost PolicyCoverage for owner

Are you working for any specific contractors or already have a sample of the insurance requirements?
Please upload any documents that may help us quote (sample COI, identification, prior coverage, etc.)

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Business Information