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COMMERCIAL insurance

WORKER'S compensation

Workers Compensation Quote

Personal Information

Owner's First Name *

Owner's Last Name *

Email Address *

Primary Phone Number *

Fax Number

Business Information

Business Name *

DBA

Business Address*

Check here if your mailing address is the same as your business Address

Mailing Address *

Business Ownership Type*

Please type in Ownership Type *

Business Information

Does your business have a Federal Employer Identification Number (FEIN)?

Yes

No

Federal Employer Identification Number (FEIN)*

Social Security Number (SSN) (Required only for sole proprietary)

Primary type of your business*

Job Description

Class Code

Number of Employees

Annual Payroll

Job Description

Class Code

Number of Employees

Annual Payroll

Job Description

Class Code

Number of Employees

Annual Payroll

Job Description

Class Code

Number of Employees

Annual Payroll

Job Description

Class Code

Number of Employees

Annual Payroll

Add more

Job Description

Class Code

Number of Employees>

Annual Payroll

Add more

Job Description

Class Code

Number of Employees

Annual Payroll

Add more

Job Description

Class Code

Number of Employees

Annual Payroll

Add more

Job Description

Class Code

Number of Employees

Annual Payroll

Add more

Job Description

Class Code

Number of Employees

Annual Payroll

Business Information

Total Number of Employees*

Number of Full Time Employees*

Number of Part Time Employees*

Number of Active Partners/Officers

Does this number include officers in Workers Comp?

Yes

No

Total Annual Payroll (excluding owners and subcontractors)*

Total Gross Income

Years of Industry Experience

In what year did you start your business?

Is the business a 24 hours operation?

Yes

No

Policy Information

Have you had any Prior Carrier?*

Yes

No

Name of the Prior Carrier*

Please Specify Prior Carrier*

Policy Expiration Date(MM-DD-YYYY):*

Policy Number (Optional):

Policy Information

Have there been losses for the lines of business submitted in the last 4 years?*

Yes

No

Please attach a copy of Loss Run from your prior Carriers in the last 4 Years*

Do you carry Group Health Insurance?*

Yes

No

Name of the Company *

Does the applicant own, operate, or lease aircraft/watercraft?

Yes

No

Any exposure to flammables, explosives, caustics, and fumes?

Yes

No

Any exposure to radioactive materials?

Yes

No

Any work performed underground or above 15 feet?

Yes

No

Any work performed on barges, vessels, and docks?

Yes

No

Is the applicant engaged in any other type of business?

Yes

No

Are subcontractors used?

Yes

No

Any work sublet without certificates of insurance?

Yes

No

Any group transportation provided?

Yes

No

Any employees under 16 or over 50 years of age?

Yes

No

Any employees over 60 years of age?

Yes

No

Any part-time or seasonal employees?

Yes

No

Is there any volunteer or donated labor?

Yes

No

Any employees with physical handicaps?

Yes

No

Do employees travel out of state?

Yes

No

Are athletic teams sponsored?

Yes

No

Are pre-employment physicals required?

Yes

No

Any other insurance with this insurer?

Yes

No

Any prior coverage declined/canceled/non-renewed in the last 3 years?

Yes

No

Certified Risk Management Program?

Yes

No

Certified Risk Management Program?

Yes

No

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