Comprehensive Workers Compensation Insurance

Complete the form below to get started with customized commercial  solutions tailored to your needs

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Workers Compensation Form

Legal Business Name *
Business Address *
State *
Type of Business *
City *
Zip Code *
Federal Tax ID Number  *
Years in Business *
Website
Contact Person *
Email *
Phone
Description of Operations  *
Do you currently have an Insurance Agent? *
Agent Name *
Agent Phone *
Agent Email *
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Owners

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Insurance Information

Do this applicant have an active Workers Compensation policy in place?  *
List Carrier Name
Effective date of policy
Expiration date of policy
Have they had any losses in the last 3 years? *
Upload loss Runs
Maximum file size: 16 MB
Upload the Accord
Maximum file size: 16 MB
Do they currently offer Voluntary Benefits?  *
List Carrier Name
Effective date of policy
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Job Descriptions and Class Codes

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Insurance

01 ) Has your workers’ compensation been non-renewed in the past 3 years? *
02 ) Current coverage in force? *
03 ) Do they own, operate or lease an aircraft/watercraft? *
04 ) Do they handle, treat, store, apply, dispose or transport hazardous material? *
05 ) Do they perform work underground or above 15 feet? *
06 ) Do they perform any work on barges, vessels, docks or bridge over water? *
07 ) Are they engaged in any other type of business? *
08 ) Do they hire subcontractors and/or independent contractors? *
09 ) Do they employees receive tips/gratuities? *
10 ) Do they sublet work without certificates of insurance? *
11 ) Do they provide any group transportation or delivery? *
12 ) Do they hire part time or seasonal employees? *
13 ) Do they have any volunteer or donated labor? *
14 ) Do they employees travel out of state? *
15 ) Do they offer health insurance? *
16 ) Do they have any anticipated debt or unpaid premiums owed to any previous workers’ compensation provider? *

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