Online Quote Application

Legal Business Name *

Applicant Name *

First

Last

Phone Number *

FEIN (Tax ID#) *

What year was your business established? *

Legal Entity Type *

Email *

Website *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Does this business have multiple locations? *

Yes No No, but the physical address is different than the mailing address provided above

PAYROLL:

On average, how many part time employees will your business have over the next 12 months? *

On average, how many full time employees will your business have over the next 12 months? *

Please provide your estimated annual payroll for each workers' compensation insurance class code.
(if you do not know the class code, you can simply describe the type of work, i.e. clerical, sales, carpenter, barber, etc.)

Class Code #1 (or Job Description) *

Number of Part-Time Employees *

Number of Full-Time Employees *

Class Code #2 (or Job Description) *

Number of Part-Time Employees *

Number of Full-Time Employees *

Class Code #3 (or Job Description) *

Number of Part-Time Employees *

Number of Full-Time Employees *

WORKERS COMP HISTORY:

How many years has the business had workers' compensation insurance coverage (if any)? *

Date for coverage to start (or current policy effective date) MM/DD/YYYY *

Has the business had any workers compensation insurance claims in the past 3 years? *

Yes No

AFfordable WORKERS COMP QUOTES WITHOUT THE HASSLE
We have you Covered

ONLINE WORKERS' COMPENSATION QUOTE APPLICATION

GENERAL:

PAYROLL:

WORKERS COMP HISTORY:

Underwriting Questions:

AFfordable WORKERS COMP QUOTES WITHOUT THE HASSLEWe have you Covered

ONLINE WORKERS' COMPENSATION QUOTE APPLICATION

GENERAL:

PAYROLL:

WORKERS COMP HISTORY:

Underwriting Questions:

AFfordable WORKERS COMP QUOTES WITHOUT THE HASSLE
We have you Covered