Workers’ Compensation Please complete the form below. Business Information Insured Name (Company Name) * Owner Name * First Name Last Name Business Type * Individual Partnership Corporation LLC Other EIN/SS * Business Description * Date of Formation * MM DD YYYY Email * Insured Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Proposed Effective Date * MM DD YYYY How long has your company been in business? * Have you had any insurance claims in the last five years? * Yes No Office Space Information What is your annual revenue? Number of Full-time Employees Number of Part-time Employees Annual Payroll for Each Clerical Annual Payroll for Each Laborer Annual Payroll for Each Owner Annual Payroll for Other Occupied Area Square Feet Is your workspace a home office or commercial location? Yes No Policy Information (Employer's Liability) Each Incident * $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 Disease-Policy Limit * $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 Disease-Each Employee * $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 Carrier Information (if applicable) Current Carrier Policy Number Premium Effective Date MM DD YYYY Owner(s) Information Name * First Name Last Name Title * Date of Birth * MM DD YYYY Payroll * $ Should be Included in the Policy? * Yes No % Ownership * Thank you for your submission. One of our agents will contact you shortly.
