WORKERS COMP INFORMATION NEEDED
Business Name ( Legal)
*
What type of entity are you?
*
LLC
INC
Sole proprietorship
Doing Business As Name (If Applicable)
*
First Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number
Federal ID Number or equivalent if a sole proprietor.
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
How many years have you been in business?
*
What are your projected gross sales a year
*
How many employees do you have?
*
What is your projected payroll (Excluding Owners) for the upcoming year
*
Tell me what all your business does
Employee Information: Name - Date of Birth - SS Number - Scope of work- WEEKLY PAYROLL
Owners Information: Name - Date of Birth - SS Number - Scope of work- Payroll Amount
Have you been running payroll for your Employees
*
Yes
No
Do you have a contract that requires you to carry of Waiver of Subrogation?
*
No
Yes
Do you have workers comp now?
*
No
Yes
Upload Workers comp loss history (regardless if you have not had losses)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are the owners or Owner of the company exempt with the Florida Works compensation department?
*
No
Yes
Workers Comp Exemption upload here
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Drag and drop files here
Choose a file
Cancel
of
Do you use subcontractors?
No
Yes
Subcontractor cost per year
*
Would you like to see if we can save you money on your home opr personal auto insurance?
*
Yes
No
Choose which one and we will have our team reach out
*
Home
Auto
How did you hear about us?
*
Google
Referral from a friend
Facebook
Sign on building
Giveaway
I know agent personally
I opt in to receive text and email *
*
Yes
No
Submit
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