FBU Work Comp Submission

Workers' Compensation Submission
Agency/Agent Information
Agency Name*
Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Your Name*

First NameLast Name
Your Email Address*
example@example.com
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applications & Files
Do you have a completed Acord 130 or other Application?*

YesNo
Please upload completed applications/Acords below:*

Cancelof
Please upload Loss Runs below (if applicable):

Cancelof
Submission Information
Insured Name*
Insured Email Address*
example@example.com
Insured Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Effective Date*

MonthDayYear
Date
Target Premium
Current Market
Is this a New Venture?*

YesNo
Years in Business*
FEIN*
EL Limits*
Does the Insured have an Experience Mod?*

YesNo
Experience Mod*
Business Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Locations*
Class Codes & Payroll*
Any Sub-Contractors?*

YesNo
% of Sub-Contractors
Owners & Officers (if known)
Any losses in the last 5 years?*

YesNo
Please provide information on each claim*
Any other information you would like to share on this submission:
Should be Empty: