Workers Compensation

Workers Compensation

Fill out to complete application process
Are you filling this out on behalf your client?*

YesNo
I am a(n)

Insurance BrokerReal Estate AgentLender / Mortgage BrokerOther
My Name*

First NameLast Name
My Email*
example@example.com
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Are you the Company Owner*

YesNo
Business Name
Entity Type*
Federal Employer ID Number
Social Security Number
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Physical Address same as Mailing Address?*

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Proposed Effective Date*

MonthDayYear
Date
State(s) in Which you do business*
Are you the only Owner?*

YesNo
How many Additional Owners are there?
What is your percentage ownership?
Date of Birth*

MonthDayYear
Date
What are your duties?
Do you want to be included or excluded from coverage?

IncludedExcluded
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 Name
Percentage Ownership of other Owner
2nd Owner's Birth Date

MonthDayYear
Date
What are his duties?
Does he want to be included or excluded from coverage?

IncludedExcluded
3rd Owner's Name
Percentage Ownership of other Owner
3rd Owner's Birth Date

MonthDayYear
Date
What are his duties?
Does he want to be included or excluded from coverage?

IncludedExcluded
4th Owner's Name
Percentage Ownership of other Owner
4th Owner's Birth Date

MonthDayYear
Date
What are his duties?
Does he want to be included or excluded from coverage?

IncludedExcluded
Contact Person*
Contact Phone Number*

Area CodePhone Number
Contact Email*
example@example.com
Description of the business
Estimated Annual Payroll*
Description of work to be performed by W-2 employees?*
Number of Employees*
Full Time Employees
Part Time Employees
Have you had Prior Workers Compensation Coverage?*

YesNo
If Yes please Upload your Loss Runs

Upload Files

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Do you Own or Operate any Aircraft or Watercraft?*

YesNo
Please explain "yes" answer
Do you treat, dispose or transport any hazardous material?*

YesNo
Please explain "yes" answer
Any work performed underground or above 15 feet?*

YesNo
Please explain "yes" answer
Any work performed on barges or vessels?*

YesNo
Please explain "yes" answer
Are you engaged in any other type of business?*

YesNo
Please explain "yes" answer
Are Subcontractors used?*

YesNo
What Percentage of work is subcontracted?
Any work sublet without certificates of insurance?*

YesNo
Is a written safety program in operation?*

YesNo
Please explain "yes" answer
Any Group Transportation provided?*

YesNo
Please explain "yes" answer
Any Employees under 16 or over 60 years of age?*

YesNo
Please explain "yes" answer
Any Seasonal Employees?*

YesNo
Please explain "yes" answer
Any Volunteer or Donated Labor?*

YesNo
Please explain "yes" answer
Any Employees with physical handicaps?*

YesNo
Please explain "yes" answer
Do Employees Travel out of the State?*

YesNo
Please explain "yes" answer
Are athletic teams sponsored?*

YesNo
Please explain "yes" answer
Are physicals required after offers of employment are made?*

YesNo
Please explain "yes" answer
Do you have any other insurance with us currently?*

YesNo
Please explain "yes" answer
Any prior coverage declined or cancelled in the last three years?*

YesNo
Please explain "yes" answer
Are Employee health plans provided?*

YesNo
Please explain "yes" answer
Do any Employees perform work for other businesses or subsidiaries?*

YesNo
Please explain "yes" answer
Do you lease Employees to other businesses or subsidiaries?*

YesNo
Please explain "yes" answer
Do Employees predominantly work from home?*

YesNo
Please explain "yes" answer
Any Tax Liens, Bankruptcies within the last 5 years?*

YesNo
Please explain "yes" answer
Any undisputed and unpaid Workers Compensation claims?*

YesNo
Please explain "yes" answer
Should be Empty: