Commercial Workers Compensation Insurance Quote
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Personal Information
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Business Information
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Policy Information
4
General Information
Personal Information
Owner's First Name
*
Owner's Last Name
*
Email Address
*
Primary Phone Number
*
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Personal Information
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Business Information
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Policy Information
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General Information
Business Information
Business Name
*
DBA
Business Address
*
Check if mailing address is different from above
Mailing Address
*
Business Ownership Type
*
Sole Proprietor
Partnership
LLC
Corporation
Joint Venture
Trust
Association
Municipality
Other
Please type in Ownership Type
*
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Personal Information
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Business Information
3
Policy Information
4
General Information
Business Information
Does your business have a Federal Employer Identification Number (FEIN)?
*
Yes
No
Federal Employer Identification Number (FEIN)
*
Social Security Number (SSN) (Required only for sole proprietary)
*
Primary type of your business
*
Job Description
Full Time
Part Time
Class Code
Number of Employees
Annual Payroll
Add Another
Remove
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Personal Information
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Business Information
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Policy Information
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General Information
Business Information
Total Number of Employees
*
Number of Full Time Employees
*
Number of Part Time Employees
*
Number of Active Partners/Officers
Does this number include officers in Workers Comp?
*
Yes
No
Total Annual Payroll (excluding owners and subcontractors)
*
Total Gross Income
Years of Industry Experience
In what year did you start your business?
Is the business a 24 hours operation?
*
Yes
No
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Personal Information
2
Business Information
3
Policy Information
4
General Information
Policy Information
Have you had any Prior Carrier?
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Yes
No
Name of the Prior Carrier
*
Travelers
Hartford
Farmers
State Farm
All State
Chubb Corp
CNA
Firemans Fund
Gaurd
AIG
CIG
Allied Nationwide Insurance
ACE
Lloyds
Other
Policy Expiration Date(MM-DD-YYYY):
*
Please Specify Prior Carrier
*
Policy Number (Optional):
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Personal Information
2
Business Information
3
Policy Information
4
General Information
Policy Information
Have there been losses for the lines of business submitted in the last 4 years?
*
Yes
No
Please attach a copy of Loss Run from your prior Carriers in the last 4 Years
*
Do you carry Group Health Insurance?
*
Yes
No
Name of the Company
*
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Personal Information
2
Business Information
3
Policy Information
4
General Information
Does the applicant own, operate, or lease aircraft/watercraft?
*
Yes
No
Any exposure to flammables, explosives, caustics, and fumes?
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Yes
No
Any exposure to radioactive materials?
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Yes
No
Any work performed underground or above 15 feet?
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Yes
No
Any work performed on barges, vessels, and docks?
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Yes
No
Is the applicant engaged in any other type of business?
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Yes
No
Are subcontractors used?
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Yes
No
Any work sublet without certificates of insurance?
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Yes
No
Any group transportation provided?
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Yes
No
Any employees under 16 or over 50 years of age?
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Yes
No
Any employees over 60 years of age?
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Yes
No
Any part-time or seasonal employees?
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Yes
No
Is there any volunteer or donated labor?
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Yes
No
Any employees with physical handicaps?
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Yes
No
Do employees travel out of state?
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Yes
No
Are athletic teams sponsored?
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Yes
No
Are pre-employment physicals required?
*
Yes
No
Any other insurance with this insurer?
*
Yes
No
Any prior coverage declined/canceled/non-renewed in the last 3 years?
*
Yes
No
Certified Risk Management Program?
*
Yes
No
Certified Risk Management Program?
*
Yes
No
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