Workers Compensation Insurance Quote Request

ABOUT THE OWNER / PRINCIPAL
Company Name:
First Name:
Last Name:
Address:
City:
State:
Phone:
Zip Code:
E-mail:
Confirm E-mail:

ABOUT THE BUSINESS
   
Location:
   
Business Structure
   
Choose the types that represent your business ( you may choose more than one):

   
Description of Business:
Year Started:    We welcome New Businesses.  
Years experience in industry:     
Tax ID # or Social      Required for most quotes.
   

Employee Information

In this section, please describe the jobs at your company and the total annual salary paid for that position. (ex: secretary, $40000).  If you know the class code, please enter it.
CLASS CODE (optional) JOB TITLE Full Time Part Time GROSS SALARY
         
         
         
         
         
         

Prior Carrier Information/ Loss History

If you had prior WC insurance, please fill out the information below
Year
Carrier #
Policy #
Annual premium
# Claims
Amount Paid:
 
 

Workers Compensation Questionnaire
YES    NO
      1. Does applicant own, operate or lease aircraft/watercraft?
      2. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc)
      3. Any work performed underground or above 15 feet?
      4. Any work performed on barges, vessels, docks, bridge over water?
      5. Is applicant engaged in any other type of business?
If yes, please list
      6. Are sub-contractors used?
If yes, give % of work subcontracted
      7. Any work sublet without certificates of ins.?
      8. Is a written safety program in operation?
      9. Any group transportation provide?
      10. Any employees under 16 or over 60 years of age?
      11. Any seasonal employees?
      12. Is there any volunteer or donated labor?
      13. Any employees with physical handicaps?
      14. Do employees travel out of state?
      15. Are athletic teams sponsored?
      16. Are physicals required after offers of employment are made?
      17. Any prior coverage declined/cancelled/non-renewed (last 3 years)?
      18. Are employee health plans provided?
      19. Is there a labor interchange with any other business/subsidiary?
      20. Do you lease employees to or from other employers?
      21. Do any employees predominately work at home?
      22. Any tax liens or bankruptcy within the last 5 years?
      23. Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises?
If yes, explain including entity name(s) and policy number(s)
   
  Please describe your business:
 

 

Where to fax/send documents:


 

Need help?

(949) 270-0609

For quotes or help in 49 states.

 

 

 

Workers Comp quotes are not available in NY or MA.