EmailMe Form - Workers Compensation

Applicant / Business Name *

D/B/A *

Company Contact or Owner *

Prefix First Last Suffix

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email Address *

Home Phone *

### - ### - ####

Business Phone

### - ### - ####

Mobile Phone

### - ### - ####

Birth Date *

MM / DD / YYYY

Business Type *

Years in Business *

Federal EIN/Tax Id

Payment Options *

Proposed Effective Date *

MM / DD / YYYY

Retroactive Date *

MM / DD / YYYY

What State is the business domiciled? *

Do you currently have Workers Compensation Insurance? *

If yes, who is the carrier?

If yes, what is the policy number?

What limits of liability are you requesting?

Each Accident *

Disease Policy Limit *

Disease Each Employee *

Is coverage requested in any other state(s)? *

If yes, which states?

What medical deductible is requested: *

What indemnity deductible is requested: *

Who is the contact for payroll and revenue audits?

Payroll/Audit Name *

First Last

Payroll/Audit Phone *

### - ### - ####

Payroll/Audit Email *

Please list all Partners, Officers, and Relatives within the company *

(Name/Title and Duties/Date of Birth/Social Security Number/Estimated Payroll/Full-Time or Part-Time/ Included or Excluded)

Please separate, classify and list total number of all employees by departments *

1)Department Description
[Example for a restaurant: Kitchen, Wait Staff, Bar Staff]
2) Number of employees in each listed department
3) Estimated Annual Payroll per each department
4) How many Full/Part Time in each department

Please give a detailed description of all duties within each listed department. *

Prior Carrier Information for past 5 years. *

(Company/Policy Period/Policy Number/Premium)

Prior Loss History for past 5 years. *

(Please attach a "5 Year Loss Run Report" which can be obtained by contacting previous insurer)

Please give a detailed description of the Nature of the Business and a Description of the Operations. *

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Does Applicant own or operate any aircraft/watercraft? *

(If yes, please give details)

Do any current or past operations include storing, treatment, discharging, applying, disposing, or transportation of any hazardous material? *

(If yes, please give details)

Any work performed underground or above 15 ft? *

(If yes, please give details)

Any work performed on barges, vessels, docks, or bridges over water? *

(If yes, please give details)

Is applicant involved in any other type of business? *

(If yes, please give details)

Are sub-contractors used? *

If yes, please give % of work sub-contracted and other details

Is any work sublet without certificates of insurance? *

(If yes, please give details)

Is there a written safety program in operation? *

(If yes, please give details)

Any group transportation provided? *

(If yes, please give details)

Any employees under 16 or over 60 years of age? *

(If yes, please give details)

Any seasonal employees? *

(If yes, please give details)

Is there any volunteer or donated labor? *

(If yes, please give details)

Any employees with physical handicaps? *

(If yes, please give details)

Do employees travel out of state? *

(If yes, please give details)

Are athletic teams sponsored? *

(If yes, please give details)

Are physicals required after offers of employment are made? *

(If yes, please give details)

Any other insurance with us? *

(If yes, please give details)

Are employee health plans provided? *

(If yes, please give details)

Any prior coverage declined/cancelled/non-renewed in the last three years? *

(If yes, please give details)

Do you lease employees to or from any other employers? *

(If yes, please give details)

Do any employees perform work for other businesses or subsidaries? *

(If yes, please give details)

Do any employees predominantly work from home? *

(If yes, please give details)

Any tax liens or bankruptcy within the last five years? *

(If yes, please give details)

Any undiputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? *

(If yes, please give details)

Any other additional information you would like to provide?

Agent