Workers Compensation

  • Workers Compensation

    Fill out to complete application process
  • Are you filling this out on behalf your client?*
  • I am a(n)
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  • Are you the Company Owner*
  • Is Physical Address same as Mailing Address?*
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  • Proposed Effective Date*
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  • Are you the only Owner?*
  • Date of Birth*
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  • Do you want to be included or excluded from coverage?

  • If there is 5 owners or more in total you will need to contact us direct here in the office to proceed with a quote.

  • 2nd Owner's Birth Date
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  • Does he want to be included or excluded from coverage?
  • 3rd Owner's Birth Date
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  • Does he want to be included or excluded from coverage?
  • 4th Owner's Birth Date
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  • Does he want to be included or excluded from coverage?
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  • Have you had Prior Workers Compensation Coverage?*
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  • Do you Own or Operate any Aircraft or Watercraft?*
  • Do you treat, dispose or transport any hazardous material?*
  • Any work performed underground or above 15 feet?*
  • Any work performed on barges or vessels?*
  • Are you engaged in any other type of business?*
  • Are Subcontractors used?*
  • Any work sublet without certificates of insurance?*
  • Is a written safety program in operation?*
  • Any Group Transportation provided?*
  • Any Employees under 16 or over 60 years of age?*
  • Any Seasonal Employees?*
  • Any Volunteer or Donated Labor?*
  • Any Employees with physical handicaps?*
  • Do Employees Travel out of the State?*
  • Are athletic teams sponsored?*
  • Are physicals required after offers of employment are made?*
  • Do you have any other insurance with us currently?*
  • Any prior coverage declined or cancelled in the last three years?*
  • Are Employee health plans provided?*
  • Do any Employees perform work for other businesses or subsidiaries?*
  • Do you lease Employees to other businesses or subsidiaries?*
  • Do Employees predominantly work from home?*
  • Any Tax Liens, Bankruptcies within the last 5 years?*
  • Any undisputed and unpaid Workers Compensation claims?*
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