Workers Compensation Insurance
Primary Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business Information
Business Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Type/Industry
*
Years in Business
*
Federal Employer Identification Number
*
Employee Information
Number of Employees
*
Number of Full-Time Employees
*
Number of Part-Time Employees
*
Please select the job classifications for your employees. If a classification is not listed, choose 'Other' and describe
*
Office Staff/Clerical
Sales Representative
Drivers
Construction Workers
Manufacturing/Assembly
Healthcare Providers
Food Service
Retail Staff
Other
Office Staff/Clerical Estimated Annual Payroll
*
Sales Representative Estimated Annual Payroll
*
Drivers Estimated Annual Payroll
*
Construction Workers Estimated Annual Payroll
*
Manufacturing/Assembly Estimated Annual Payroll
*
Healthcare Providers Estimated Annual Payroll
*
Food Service Estimated Annual Payroll
*
Retail Staff Estimated Annual Payroll
*
Other Estimated Annual Payroll
*
Do you employ contractors?
*
Yes
No
Number of contractors
*
Please describe the type of work performed by the contractors
*
Contractor Annual Cost
*
Current Insurance
Do you currently have Workers Compensation Insurance?
*
Yes
No
Current Insurance Carrier
*
Current Policy Expiration Date
*
-
Month
-
Day
Year
Date
Any previous claims in the past 5 years?
*
Yes
No
Provide details on each claim
*
Desired Coverage
Preferred Workers Compensation Coverage Limits (Per Accident)
*
$100,000
$500,000
$1,000,000
$2,000,000
Custom
Preferred Workers Compensation Coverage Limits (Per Employee)
*
$100,000
$500,000
$1,000,000
$2,000,000
Custom
Preferred Workers Compensation Coverage Limits (Per Policy)
*
$100,000
$500,000
$1,000,000
$2,000,000
Custom
Do employees work in multiple states?
*
Yes
No
Safety and Risk Management
Does your business have a written safety program?
*
Yes
No
Do you conduct regular safety training?
*
Yes
No
Are you compliant with Occupational Safety and Health Administration (OSHA) standards?
*
Yes
No
Number of On-Site Safety Managers
*
Put '0' if not applicable
Additional Information
Submit
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