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?
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
2 digit month, 2 digit day, 4 digit yearDate
Target Premium
Current Market
Is this a New Venture?
Years in Business
FEIN
EL Limits
Does the Insured have an Experience Mod?
Experience Mod
Business Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Locations
Class Codes & Payroll
Any Sub-Contractors?
% of Sub-Contractors
Owners & Officers (if known)
Any losses in the last 5 years?
Please provide information on each claim
Any other information you would like to share on this submission:
Should be Empty: