Contact Information

Full Name *

Title/Position *

Phone *

Email *

Business & Operations Details

Describe Business Operations *

Does your business operate in multiple states? *

If yes, please name them below

States of Operations

Do you use subcontractors? *

If yes, do you require them to carry their own Workers' Compensation?

Estimated Gross Revenue *

Payroll & Employee Breakdown

Please provide the estimated annual payroll and employee count per job description (e.g., Office/Clerical, Outside Sales, Construction/Labor, Drivers).

Job Description *

Number of Full-Time Employees *

Number of Part-Time Employees *

Estimated Annual Payroll *

Job Description 2

Total Estimated Annual Payroll (All Employees combined) *

Insurance History & Claims

Current Workers' Comp Insurance Carrier *

Current Policy Expiration Date *

Have you had any workers' comp claims or workplace injuries in the past 3 years? *

If yes, please briefly describe the claims or total amount paid

Submission Notes: To speed up your quote, please attach a copy of your Current Policy Declaration Page and a 3-Year Loss Run Report (claims history) if available.

Safety Program

Do you have a written safety program? *

Are safety meetings conducted regularly? *

Are new employees required to complete safety training? *

Do you have a return-to-work program? *

Is personal protective equipment (PPE) required? *

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