Workers Compensation
  About Your Company
 
Company Name* :
Your First Name* :
Last Name* :
Email* :
Email address (retype)* :
Street Address* :
City* :
Select State* :
Zip* :
Phone (Day)* :
Phone (Evening) :
Fax :
     
When would you like to be contacted? : No Preference Morning
Afternoon Evening
     
 
Sole Proprietorship Partnership Corporation LLC Association
Do you have an Workers Compensation policy? : Yes No
    If "Yes", when does your current policy expire?
   
    If "Yes," who are you currently insured with?
   
Description of Your Business :
Number of years in business :
Number of Locations to be covered :
Please list the location address(es) :
Please list the names of all owners/officers and specify if they should be included or excluded:
Officer 1: Title
  Include? Yes No
Officer 2: Title
  Include? Yes No
Officer 3: Title
  Include? Yes No
Number of Employees (excluding officers/owners) :
Approximate Annual Payroll :
Breakdown of Employee Payroll: If your business is a new venture, enter the projected payrolls. Please note that all Workers Compensation policies are subject to an audit.
Class Code or Job Description Payroll
Has your company had any claims in the last 3 years? : Yes No
    If "Yes", briefly explain:
   
Any Comments / Questions? :