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Online Workers' Compensation Quote Application
We make it
quick & easy
to secure the lowest workers' compensation insurance quotes on the market. Simply complete the online Quote Application below and receive quote indications in as little as same day!
GENERAL:
*
Indicates required field
Legal Business Name
*
Applicant Name
*
First
Last
Phone Number
*
FEIN (Tax ID#)
*
What year was your business established?
*
Legal Entity Type
*
Corporation
Partnership
Limited Liability Company
Sole Proprietorship
Other
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?
*
Exclude: Officers, owners and partners. Include: Contractors who don’t have workers’ compensation insurance.
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
*
Estimated Annual Payroll for Class Code #1
*
Class Code #2 (or Job Description)
*
Number of Part-Time Employees
*
Number of Full-Time Employees
*
Estimated Annual Payroll for Class Code #2
*
Class Code #3 (or Job Description)
*
Number of Part-Time Employees
*
Number of Full-Time Employees
*
Estimated Annual Payroll for Class Code #3
*
Do you have more than 3 class codes on your policy?
*
Yes
No
WORKERS COMP HISTORY:
How many years has the business had workers' compensation insurance coverage (if any)?
*
Less than a year
1 year
2 years
3 years
More than 3 years
No prior coverage/first time applying for coverage
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
Underwriting Questions:
Please check any items below to indicate "yes" to the question.
Check all that apply
*
Do employees work from home under normal circumstances?
Does the insured have any individuals working unpaid (e.g. volunteers, interns, family members)?
Does the insured have any operations after 2AM (except for hotels & motels)?
Are there any instances where an employee will need to lift something (e.g. products, objects, people, animals) weighing more than 50lbs?
Does the insured expect to pay for the service of 1099 employees, cash workers, or subcontractors?
Has the insured operated under a different legal name, legal entity or doing business as (DBA) name within the last 5 years?
Does the insured have any operations or exposure outside the United States?
Does the insured have any employees that drive more than 10% of the time?
Do clerical workers or salespersons perform any installation, delivery services, or door-to-door sales?
Does the insured operate as a staffing company, PEO, employee leasing company, freight forwarder, paper contractor or any similar operation?
NONE of these apply
Submit
HOME
ABOUT
FOUNDER STORY
BLOG
CONTACT
WORKERS COMP INSURANCE
WHO WE INSURE
>
High-Risk
Contractors
Health Care
Restaurants
Professional Services
Personal Care
Child Care
Hospitality
APPLY FOR QUOTES ONLINE