General Liability + Workers Compensation

General Liability + Workers Compensation
Company Name*
Phone Number*
Please enter a valid phone number.
Existing Applicant?*

YesNo
EZLynx URL*
Please confirm the customer address, email, and phone number. Does the current info match EZlynx?*

Yes, it's correctNo, we need to update.
Describe the changes:

Estimated Annual Revenue/Gross Sales*
This is the TOTAL amount received for your services before taxes and expenses.

List ALL types of work performed separately. Additionally, add the estimated employee/subcontractor payroll for each type of work.

Total % of Work*
⚠️The percentages must total 100%. Please check your entities.⚠️*
How many employees/helpers do you have?*
Do you have employees, helpers, or use subcontractors?

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?
What do you estimate the total annual payroll to be for insured subcontractors?
Total Employee Payroll*
Total Subcontractor Payroll*
Do all subcontractors provide you a Certificate of Insurance (COI), with your company name listed as the Certificate Holder? If not, GO BACK to the previous page and add them as UNINSURED subcontractors.*

Yes, I keep copies of COI
Do the owner(s) do the same type of work as above? Or do owner(s) only supervise or do administrative work?*

Do you want a quote for General Liability?*

YesNo
Describe your current coverage status*

I currently have general liability insuranceI had coverage but it was cancelled/expiredI have never had general liability insurance
What is/was the expiration date of your current/prior policy?*
What insurance carrier?
In the last 5 years have you had any losses or filed any claims? Please also request the LOSS RUNS in case this is requested. You can upload at the end of the form or send to us later!

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.

Do you want a quote for Workers Compensation?*

YesNo
Describe your current coverage status*

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?
In the last 5 years have you had any losses or filed any claims? Please also request the LOSS RUNS in case this is requested. You can upload at the end of the form or send to us later!

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.
Since you have no employees, do you want a "ghost policy" (minimum coverage, only used to send proof of insurance) or coverage for yourself as the owner? *Coverage for the owner is more expensive.

Minimum coverage/Ghost PolicyCoverage for owner
How much do you pay yourself as the 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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