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Workers Compensation Form

Legal Business Name *
Type of Business *
City *
Address *
State *
Zip Code *
Federal Tax ID Number  *
Website
Contact Person *
Email *
Phone
Agent/Referral Name
Agent/Referral Phone
Agent/Referral Email
Description of Operations  *
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Owners

Owner Name *
Title *
Ownership % *
Included or excluded *
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Insurance Information

Date Business Established  *
Do you have an active Workers Compensation policy in place?  *
List Carrier Name
Effective date of policy
Have you had any losses in the last 3 years? *
Upload loss Runs
Maximum file size: 16 MB
Upload the Accord
Maximum file size: 16 MB
Do you currently offer Voluntary Benefits?  *
List Carrier Name
Effective date of policy
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Job Descriptions and Class Codes

Job Description/ Class Code *
Full time employees *
Part-time employees *
Estimated Annual Payroll *
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Insurance

01 ) Has your workers’ compensation been non-renewed in the past 3 years? *
02 ) Do you currently have coverage in force? *
03 ) Do you own, operate or lease an aircraft/watercraft? *
04 ) Do you handle, treat, store, apply, dispose or transport hazardous material? *
05 ) Do you perform work underground or above 15 feet? *
06 ) Do you perform any work on barges, vessels, docks or bridge over water? *
07 ) Are you engaged in any other type of business? *
08 ) Do you hire subcontractors and/or independent contractors? *
09 ) Do your employees receive tips/gratuities? *
10 ) Do you sublet work without certificates of insurance? *
11 ) Do you provide any group transportation or delivery? *
12 ) Do you hire part time or seasonal employees? *
13 ) Do you have any volunteer or donated labor? *
14 ) Do any employees travel out of state? *
15 ) Do you offer health insurance? *
16 ) Do you have any anticipated debt or unpaid premiums owed to any previous workers’ compensation provider? *

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