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Customer Information
 
1) How many total people will need to be covered by this Workers' Compensation insurance?
  (Use numbers only -- e.g., 10, not ten.)
2) What is the breakdown of these individuals?
  Owners and/or Partners:

Full-time Employees:       

Part-time Employees:      

Sub-contractors/Consultants:

3) Briefly describe the job function(s) of these employees that you wish to cover.
 
4) Is this coverage needed for a one-time or seasonal event?
  Yes
No
5) How many years has your company been in business?
 
6) Do you currently have Workers' Compensation insurance?
  Yes
No
8) Have you had workers' comp claims filed against your company within the last 3 years?
  Yes
No
10) When would you like your plan to take effect?
  ASAP
Within one month
In one to two months
More than two months
When my current policy expires
11) Please list your most recent calendar year gross payroll:
  Under $100,000
$100,000 - 249,999
$250,000 - 499,999
$500,000 - 999,999
$1,000,000+
12) What is your business entity (legal entity)?
 
13) What industry is your company in?
 
14) Please describe your business in detail. (e.g. products or services provided, etc.)
 
First Name:
Last Name:
Company Name:
Email Address:
No. of Employees:
Phone Number: - -
Street Address:
City:
State:
Zip Code:
 
 

Contact Us
Name:
Phone:  -  -
Email:
Zip Code:
Message:
Currently have an Insurance Policy?
You can Fax us a copy of your policy at 866-206-7702 and a agent will contact you."

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