Worker's Compensation Application

EPLI Available.
(Please request application from (800) 400-3276)

Please complete the form below and click the submit button to complete the application.

Fields marked with (*) are required fields.

Application works only in Microsoft Internet Explorer - Compatability View and Mozilla Firefox, does not work in Google Chrome

Agent Informations

Agency*

Agent Name*

Agent Phone*

Fax*

Email Address*

Would you like the quote sent* Fax Email

Policy Information

Proposed Effective Date*

Proposed Expiration Date*

Application Information

Business Name*

Owner(s) Name*

Phone (Area Code, Number & Ext.)

Does this entity own other businesses or buildings not covered by this policy? If yes, please describe*

Type of Business*

Current / Prior Carrier: (Include Company Name, Coverage Types, Line of Business and Dates.)*

Has policy been cancelled or non-renewed in past 3 years? If yes, please describe* Yes No

If yes, please describe

Any claims in the last 3 years? (Package Only)* Yes No

If yes, please explain and include : Description, Date, Amount Paid, and What has been done since to prevent a reoccurence?

Fields marked with (*) are required fields.

Location

Location Address: (Include County & Zip)*

Years in Business*

Years of Experience

Mailing Address: (Only if different than location address above. - Include City, State & Zip)

Interest*

Attachments

Please attach any additional documents needed for your submission, click the folder below to select one or more files.

Your application has not been submitted yet. Please review all of your answers below and
click the submit button at the bottom of this page to complete your application

If your workers compensation application is to a CONTRACTOR, this FORM needs to be completed and submitted.

Agency

Agent Name

Agent Phone

Fax

Email Address

Would you like the quote sent

Proposed Effective Date

Proposed Expiration Date

Business Name

Owner(s) Name

Phone (Area Code, Number & Ext.)

Does this entity own other businesses or buildings not covered by this policy? If yes, please describe

Type of Business

Current / Prior Carrier: (Include Company Name, Coverage Types, Line of Business and Dates.)

Has policy been cancelled or non-renewed in past 3 years? If yes, please describe

If yes, please describe

Any claims in the last 3 years? (Package Only)

If yes, please explain and include : Description Date Amount Paid What has been done since to prevent a reoccurence?

Location Address: (Include County & Zip)

Years in Business

Years of Experience

Mailing Address: (Only if different than location address above. - Include City, State & Zip)

Classification of Business: (Short Version)

Business Web Site Address: (If Any)

Description of Operations / Occupancy: (Be as detailed as possible - 10 words minimum!) (All Tenants with Sq. Ft. for Lessors Risk)

EPLI Insurance in place? (If Applicable)

Company

Effective Dates

Policy Number

Commerical Automobile Coverage?

Commercial Umbrella Coverage? Please Send Accord

Workers Compensation Coverage? Please See Below To Get Quote

Technology & Misc. E&O, D&O, EPL

FEIN Number (Must have a FEIN to get a W/C quote.)

class1

$

class2

$

class3

$

Name of excluded person, Title, Ownership %, Duties

Full Time

Part Time

What is your target for Workers Compensation?

Effective Date:

Have there been any losses in the last 3 years? If so, please send Loss Runs

Additional Comments

What is your target premium on package? $

Applicant Signature/Print Name

Agent/Producer Signature/Print Name

Captcha

Please insert appropriate characters to submit request

Thank you for submitting your request. Please use the links on the top of this page to continue browsing our web site.

If your workers compensation application is to a CONTRACTOR, this FORM needs to be completed and submitted.