Workers Compensation Application
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Reason for insurance request:
New in business Currently in business with no prior insurance
They are Cancelling my Account Account is going to Non-Renew Searching for a better price
Applicant Information
Company Name: DBA:
Street Address:
City: State:
Zip Code:
Phone: Fax:
Email:
Website:
Years in business:
Years in industry:
Federal Tax ID or Social Security Number (Required for Quoting)

State the nature of business / description of operations with proposed effective date: Please be detailed in your description.
Locations
#
  Street, City, County, State, Zip
List other states you have workers compensation:

Current number of employees:
Fulltime: Part time: Seasonal:
- under the age of 18 -Over the age of 65
 
Payroll Information
Job Title Annual Payroll Description of Job
 
Corporate Officers/Partners to be Excluded
Name Title Ownership % Annual Salary DOB
% $
% $
% $
% $
 
Prior Carier Information / Loss History (Provide Last Five Year Loss History And Details)
Year Carrier Policy Number Annual Premium # Of Claims Claims Amount Paid
$ $
$ $
$ $
 
 
Does insured have any locations outside of this state? Yes No
Any lapse of coverage? Yes No
Does the insured have a radius of travel greater than 200 miles? Yes No
Does applicant own, operate or lease aircraft/watercraft? Yes No
Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, or transporting of hazardous materials? Yes No
Any work performed underground or above 15 feet? Yes No
Any work performed on barges, vessels, docks, bridges over water? Yes No
Is applicant engaged in any other type of business? Yes No
Are sub-contractors used? Yes No
Any work sublet without certificates of insurance? Yes No
Is a written safety program in operation? Yes No
Any group transportation provided? Yes No
Any employees under 16 or over 60 years of age? Yes No
Any seasonal employees? Yes No
Is there any volunteer or donated labor? Yes No
Any employees with physical handicaps? Yes No
Do employees travel out of state? Yes No
Are athletic teams sponsored? Yes No
Any prior coverage declined, cancelled, non-renewed (last 3 yrs?) Yes No
Are employee health plans provided? Yes No
Is there a labor interchange with any other business/subsidiary? Yes No
Do you lease employees to or from other employers? Yes No
Do any employees predominantly work at home? Yes No
Any tax liens or bankruptcy within the last 5 years? Yes No
Any undisputed and unpaid work comp premium due from you or any commonly managed or owned enterprises? Yes No

Please explain any "Yes" responses:
Please let us know the best time to contact you?
Referral by:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.