Workers Compensation

Workers Compensation

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

Yes No
I am a(n)

Insurance Broker Real Estate Agent Lender / Mortgage Broker Other
My Name *

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

Area Code Phone Number
Name *

First Name Last Name
Are you the Company Owner *

Yes No
Business Name
Entity Type *
Federal Employer ID Number
Social Security Number
Physical Address *

Street Address

Street Address Line 2

City State / Province

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

Yes No
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Proposed Effective Date *

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

Yes No
How many Additional Owners are there?
What is your percentage ownership?
Date of Birth *

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

Included Excluded
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

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

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

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

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

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

Included Excluded
Contact Person *
Contact Phone Number *

Area Code Phone 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? *

Yes No
If Yes please Upload your Loss Runs

Upload Files

Cancel of
Do you Own or Operate any Aircraft or Watercraft? *

Yes No
Please explain "yes" answer
Do you treat, dispose or transport any hazardous material? *

Yes No
Please explain "yes" answer
Any work performed underground or above 15 feet? *

Yes No
Please explain "yes" answer
Any work performed on barges or vessels? *

Yes No
Please explain "yes" answer
Are you engaged in any other type of business? *

Yes No
Please explain "yes" answer
Are Subcontractors used? *

Yes No
What Percentage of work is subcontracted?
Any work sublet without certificates of insurance? *

Yes No
Is a written safety program in operation? *

Yes No
Please explain "yes" answer
Any Group Transportation provided? *

Yes No
Please explain "yes" answer
Any Employees under 16 or over 60 years of age? *

Yes No
Please explain "yes" answer
Any Seasonal Employees? *

Yes No
Please explain "yes" answer
Any Volunteer or Donated Labor? *

Yes No
Please explain "yes" answer
Any Employees with physical handicaps? *

Yes No
Please explain "yes" answer
Do Employees Travel out of the State? *

Yes No
Please explain "yes" answer
Are athletic teams sponsored? *

Yes No
Please explain "yes" answer
Are physicals required after offers of employment are made? *

Yes No
Please explain "yes" answer
Do you have any other insurance with us currently? *

Yes No
Please explain "yes" answer
Any prior coverage declined or cancelled in the last three years? *

Yes No
Please explain "yes" answer
Are Employee health plans provided? *

Yes No
Please explain "yes" answer
Do any Employees perform work for other businesses or subsidiaries? *

Yes No
Please explain "yes" answer
Do you lease Employees to other businesses or subsidiaries? *

Yes No
Please explain "yes" answer
Do Employees predominantly work from home? *

Yes No
Please explain "yes" answer
Any Tax Liens, Bankruptcies within the last 5 years? *

Yes No
Please explain "yes" answer
Any undisputed and unpaid Workers Compensation claims? *

Yes No
Please explain "yes" answer
Should be Empty: