Workers Compensation Application

Address

Company Address

Owners Name
Type of Business
Fed Tax ID
License Type
License#
Yrs. in Business
# Full-Time

- Area Code Phone Number
# Part-Time

- Area Code Phone Number
Locations
Square Footage
Annual Gross $
Est. Monthly Payroll
Please describe your Business
Current Carrier Information
Carrier
How many years with?
Premium Amount
MOD Factor
Claim Amount Paid
Losses in the last 3 years
Owners / Partners / Officers
Full Name
Title
Ownership %
Payroll Information
Class Code
Employee Duties
Annual Payroll
Hourly Wage
General Information
MOD Factor
Do you offer safety programs? Do you offer health insurance to the majority of employees? Do you employ any minors (under 18)? Operation all/part of exist. business purch/acq? Do use subcontractors? Use any equipment that bends/shapes/forms? Are athletic teams sponsored? Been a lapse in coverage during past 12 months? Any work above 15 feet? Had a bankruptcy in past 7 years? Are a member of any trade organizations?
Please Read

By completing and submitting a form, you agree that no coverage is bound, no policy is in effect and no changes are made until you are contacted by one of our representatives.

All information submitted will only be used for the purpose of completing your request to explore insurance opportunities.
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Company Information