Get a quote today Get Your Personalized Workers’ Comp Quote Now 1 2 3 4 5 6 Last Page Workers Compensation Form Legal Business Name * Type of Business * SelectSole ProprietorPartnershipNon ProfitCorporationLLC City * Address * State * Select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Federal Tax ID Number * Website Contact Person * Email * Phone Agent/Referral Name Agent/Referral Phone Agent/Referral Email Description of Operations * Next 1 2 3 4 5 6 Last Page Owners Owner Name * Title * Ownership % * Included or excluded * SelectIncludeExclude Owner Name Title Ownership % Included or excluded SelectIncludeExclude × Add new Back Next 1 2 3 4 5 6 Last Page Insurance Information Date Business Established * Do you have an active Workers Compensation policy in place? * SelectYesNo List Carrier Name Effective date of policy Have you had any losses in the last 3 years? * SelectYesNo Upload loss Runs Maximum file size: 16 MB Upload the Accord Maximum file size: 16 MB Do you currently offer Voluntary Benefits? * SelectYesNo List Carrier Name Effective date of policy Back Next 1 2 3 4 5 6 Last Page Job Descriptions and Class Codes Job Description or Class Code * Full time employees * Part-time employees * Estimated Annual Payroll * Job Description or Class Code Full time employees Part-time employees Estimated Annual Payroll × Add new Back Next 1 2 3 4 5 6 Last Page Insurance 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 Back Submit