Workers Compensation Insurance

Workers Compensation Insurance Quotation Form
Proposed Effective Date

MonthDayYear
Date
Applicant / Company Name
Company Name
Business Structure
FEIN /Tax ID
Business Phone Number
Years in Business
Business Description
Business Description
Mailing Address / Business Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name

First NameLast Name
Contact E-Mail
Email
Contact Phone number

Policy Information
EMPLOYEES INCLUDED / EXCLUDED

Officers and Owners Included / Excluded

Rows	Name	Own%	Duties	Payroll	Inc/Excl
Empl1
Empl2
Empl3
Empl4

STATE RATING

Workers Comp Rating Worksheet

Rows	Classification	Payroll Amount	# full time employees	# of Part time employees
1
2
3
4

For others classification, please describe :

Prior Carrier Information / Loss History
Any Claims in the last 5 years?
Describe what type of Claim
Date

MonthDayYear
Date
Do you currently have a Workers Compensation Insurance Policy?
Previous Policy
You can upload a copy of the policy here (Optional)

Browse Files

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General Information
PLEASE READ AND REVIEW ALL QUESTIONS BELOW CAREFULLY. THEY ARE ALL SELECTED AS NO BY DEFAULT
1. Does the business have more than 50 people working at one location at a time?
2. Does the business currently have workers compensation coverage in effect?
3.In the past 2 years has business had 2 or more Workers Compensation claims, a single Workers Compensation claim over 20k, or any employee who suffered work related injury requiring more than 2 das off of work?
4. Does the applicant make any deliveries using a motorized scooter or moped?
5 Does the applicant operate as a discotheque, night club, dance club, dance hall, hookah lounge or provide adult entertainment?
6. Does applicant operate as a food truck,meals on wheels or street vendor / food concessionaire?
7. Is the applicant open 24 hours?
8. Are ANY of the following true? The applicant makes more than 10 deliveries per day on average,the applicant makes deliveries after 10pm, the applicant makes deliveries on food or by bicycle?
9. Does the applicant have a wait staff?
10. DO / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)
14. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
15. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
16. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
17. ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)
18. IS A WRITTEN SAFETY PROGRAM IN OPERATION?
19. ANY SEASONAL EMPLOYEES?
20. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
21. Is worked performed in any other states (If "YES", indicate state(s) )
22. Any Prior coverage declined/ canceled / non renewed in the last three (3) years? (Missouri Applicants - Do not answer this question.)
23. Do any employees perform work for other businesses or subsidiaries?
24. Any Tax Liens or Bankruptcy within the last Five (5) Years? (If “YES”, Please specify)
Please explain any "YES" answers above.
Referred by:
Please verify that you are human
Sign Signature
Should be Empty:

Workers Compensation Insurance Quotation Form

Policy Information

Prior Carrier Information / Loss History

General Information