Worker's Compensation Insurance / PEO Quote Request
**Please note that at this time, we are not writing Minimum-Earned Premium Policies (Ghost Policies)**
Contact Information
Business Name
*
Business Type
*
Sole Proprietor
Limited Liability Corporation (LLC)
Corporation
FEIN:
*
Contact Name
*
First Name
Last Name
Contact Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Sorry, We are not licensed in your state, but we have options!
Unfortunately at this time, we are not licensed in your particular state for standard carriers, but we do have options through a Professional Employment Organization (PEO) or Staffing Companies that we can explore.
About Your Business
What type of business do you do?
*
Please select the activity which closest relates to you. You can start typing in the box and it will attempt to auto-fill according to your profession.
What date are you looking to have coverage in place?
*
-
Month
-
Day
Year
Date
How many owners are there for the company?
*
1
2-3
3+
How many W-2 employees do you have?
*
0 (I am the owner and have no employees)
1-3
4-10
10+
You've indicated that you have no employees and only the owners are looking for workers' compensation. Are you being contractually required to have workers compensation?
*
Yes
No
I Don't Know
What is your total employee payroll?
*
$15,000 - $25,000
$25,000 - $50,000
$50,000 - $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000+
Do you plan on getting or already possess workers compensation exemptions for the owners of of the company?
*
Yes
No
Notice - Owner Only Payroll
You have indicated that you have no employees. The owners would be rated as the only employee(s) of the company at the state minimum officer payroll unless you have obtained an exemption.
Do you use 1099 subcontractors?
*
Yes
No
What type of work do the subcontractors do?
*
What are your total subcontractor costs?
*
$15,000 - $25,000
$25,000 - $50,000
$50,000 - $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000+
Do you currently have workers' compensation coverage?
*
Yes
No
Who is your carrier?
*
What is the reason for possibly wanting to leave the carrier you are with?
*
Have you had workers' comp coverage in the past?
*
Yes
No
How many years of continuous workers' comp have you had?
*
1 - 3 Years
3 - 5 Years
5 Years +
Who was your previous carrier?
Worker's Comp Report Acknowledgement
In order to get you a quote, we are going to need to run a report from your state's workers' compensation database regarding your company. All this is going to do is authorize our agency to gather data about previous coverage history. Please sign on the line below granting Zellner Insurance Agency permission to run this report.
Please sign below
Notice - Minimum Earned Premium Policy / Ghost Policy
From the information you have provided, it seems as if you are trying to obtain a minimum earned premium / ghost policy. This is a policy in which there are no employees present and you, owner, are exempt from coverage. At this time, BrightComp is not writing this specific type of policy.
Submit
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