Workers' Compensation Quote

1
Legal Business Name:* This field is required.Including DBA names.
2
Legal Structure* This field is required.
Sole Proprietor
Partnership
Corporation
LLC
PLLC
Other (please specify)
Other (please specify)
3
Practice Type:* This field is required.
Small Animal Exclusive
Predominantly Small Animal
Predominantly Large/Food Animal
Equine Exclusive
4
Practice Owner's Name* This field is required.
5
Insurance Contact's Name:* This field is required.If different from practice owner's.
6
Telephone Number:* This field is required.
7
Practice Address: * This field is required.
8
Mailing Address: If different from practice address.
9
Email* This field is required.For security reasons, please provide a private email address not shared by multiple employees.
example@example.com
10
Years in Business:* This field is required.
11
Estimated Total Assets ($):
12
FEIN:* This field is required.Federal Employer Identification Number
13
Do you currently use a payroll service?
Yes
No
Unsure
14
Expiration date of your current workers' compensation policy written through another agent or program.* This field is required.If no policy exists, please enter the desired effective date of a new policy.
15
What is your current workers' compensation policy carrier and annual premium?
16
What is your experience modification factor?
17
Please provide the employee count and payroll information for animal handlers in your practice* This field is required.Enter zero (0) for groups that do not apply.
Animal Handlers: Number of full-time employees
Animal Handlers: Number of part-time employees
Animal Handlers: Estimated gross annual payroll
18
Please provide the employee count and payroll information for owners and officers in your practice* This field is required.Enter zero (0) for groups that do not apply.
Owners and officers (no animal contact): Number of full-time employees
Owners and officers (no animal contact): Number of part-time employees
Owners and officers (no animal contact): Estimated gross annual payroll
19
Please provide the employee count and payroll information for clerical staff in your practice* This field is required.Enter zero (0) for groups that do not apply.
Clerical Staff (no animal contact): Number of full-time employees
Clerical Staff (no animal contact): Number of part-time employees
Clerical Staff (no animal contact): Estimated gross annual payroll
20
List the names of all owners and officers that you would like to INCLUDE in coverage:
21
List the names of all owners and offices that you would like to EXCLUDE from coverage:
22
Would you like to include coverage for the spouse of an owner or officer who is an employee of the practice?
23
List all claims that occurred the past four years including date, approximate amount paid, and injury type:Injury Type = animal bite/scratch, lifting sprain/strain, slip/trip/fall, other (please explain)
24
List all workers' compensation claims that occurred the past four years including date, approximate amount paid, and injury type:* This field is required.Workers' compensation Injuries typically include (but are not limited to): animal bite/scratch, lifting sprain/strain or slip/trip/fall. Please elaborate on any other claims.
Huge
Large
Normal
Small
Ok
Ok
25
Check all that apply regarding your current safety program:* This field is required.
Formal training for new hires
Employee handbook required to be read and signed by all employees
Routine safety meetings for new and current employees
Training on proper lifting techniques
Adequate safeguards on equipment/machinery
Positive management attitude towards safety
OSHA compliance
Exam Tables that raise and lower
Aggressive animal policy
Protective clothing for handling animals
Disciplinary Program when employee does not follow safety protocol
Return to work program
First aid kits readily available
None of the above
Should be Empty: