Commercial Workers Compensation Insurance Quote

Owner's First Name *

Owner's Last Name *

Email Address *

Primary Phone Number *

Business Name *

DBA

Business Address*

Check if mailing address is different from above

Business Ownership Type*

Does your business have a Federal Employer Identification Number (FEIN)?*
Yes No

Primary type of your business*

Job Description

Class Code

Number of Employees

Annual Payroll

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

Have you had any Prior Carrier?*
Yes No

Name of the Prior Carrier*

Policy Expiration Date(MM-DD-YYYY):*

Policy Number (Optional):

Have there been losses for the lines of business submitted in the last 4 years?*
Yes No

Do you carry Group Health Insurance?*
Yes No