Get a quote today Get Your Personalized Workers’ Comp Quote Now Business Information Legal Business Name Type of Business Select Sole Proprietor Partnership Non Profit Corporation LLC Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawái Idaho Illinois Indiana Iowa Kansas Kentucky Luisiana Maine Maryland Massachusetts Míchigan Minnesota Misisipi Misuri Montana Nebraska Nevada Nueva Hampshire Nueva Jersey Nuevo México Nueva York Carolina del Norte Dakota del Norte Ohio Oklahoma Oregón Pensilvania Rhode Island Carolina del Sur Dakota del Sur Tennessee Texas Utah Vermont Virginia Washington Virginia Occidental Wisconsin Wyoming Zip Code Contact Person Website Years In Business Federal Tax ID Number Email Phone Referral Name Referral Phone Referral Email Description of Operations Owner Name Ownership % Title Date of Birth Owner 2 Name Ownership % Title Date of Birth Owner 3 Name Ownership % Title Date of Birth Insurance Information Do You Have a Workers Comp? Select Yes No If yes, list Carrier Name Effective Date Have you had any losses in the last 3 years? Select Yes No If yes, list Carrier Name Upload Loss Runs Do you currently offer Voluntary Benefits? Select Yes No If yes, list Carrier Name Effective Date Job Descriptions and Class Codes Annual Payroll Number of Employees Job Description or Class Code Annual Payroll Number of Employees Job Description or Class Code Annual Payroll Number of Employees Job Description or Class Code 01 ) Has your workers’ compensation been non-renewed in the past 3 years? Yes No 02 ) Do you currently have coverage in force? Yes No 03 ) Do you own, operate or lease an aircraft/watercraft? Yes No 04 ) Do you handle, treat, store, apply, dispose or transport hazardous material? Yes No 05 ) Do you perform work underground or above 15 feet? Yes No 06 ) Do you perform any work on barges, vessels, docks or bridge over water? Yes No 07 ) Are you engaged in any other type of business? Yes No 08 ) Do you hire subcontractors and/or independent contractors? Yes No 09 ) Do your employees receive tips/gratuities? Yes No 10 ) Do you sublet work without certificates of insurance? Yes No 11 ) Do you provide any group transportation or delivery? Yes No 12 ) Do you hire part time or seasonal employees? Yes No 13 ) Do you have any volunteer or donated labor? Yes No 14 ) Do any employees travel out of state? Yes No 15 ) Do you offer health insurance? Yes No 16 ) Do you have any anticipated debt or unpaid premiums owed to any previous workers’ compensation provider? Yes No Agent Information Agency Name Agent First Name Agent Last Name Agent Email Agent Phone Number Submit One Workers Comp Request a Quote Business Information Legal Business Name * Type of Business * -Select-Sole ProprietorPartnershipNon ProfitCorporationLLC Address * City * State * -Select-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Contact Person * Website Years in Business * Federal Tax ID Number * Email * Phone Referral Name Referral Phone Referral Email Description of Operations * If you are human, leave this field blank. Next