Takes about 10 minutes. The more complete it is, the faster we can prepare your quote.
Fields marked * are required. The more you can complete, the faster we can prepare your quote.
Legal Business Name *
Mailing Address — Street *
Legal Entity Type Sole ProprietorCorporationSubchapter S CorpPartnershipLLCJoint VentureTrustAssociationUnincorporatedOther
Employers’ Liability Limit Requested
Other coverages or endorsements needed (optional)
List the physical locations where work is performed.
Location 1 — Street, City, County, State, ZIP
Location 2 — Street, City, County, State, ZIP (optional)
Indicate whether each owner/officer is included in or excluded from coverage.
Owner / Officer 1
Owner / Officer 2 (optional)
List your job classifications / duties and estimated annual payroll.
Describe your business, operations, products and services *
I will provide loss runs for the past 5 years
Most recent year
Prior year
Answer each question, then explain any “Yes” answers in the box at the end.
1. Do you own, operate, or lease aircraft or watercraft?YesNo
2. Do/have your operations involve(d) storing, treating, discharging, disposing of, or transporting hazardous materials?YesNo
3. Is any work performed underground or above 15 feet?YesNo
4. Is any work performed on barges, vessels, docks, or bridges over water?YesNo
5. Are you engaged in any other type of business?YesNo
6. Are subcontractors used?YesNo
7. Is any work sublet without certificates of insurance?YesNo
8. Is a written safety program in operation?YesNo
9. Is any group transportation provided?YesNo
10. Are any employees under 16 or over 60 years of age?YesNo
11. Are there any seasonal employees?YesNo
12. Is there any volunteer or donated labor?YesNo
13. Are there any employees with physical handicaps?YesNo
14. Do employees travel out of state?YesNo
15. Are athletic teams sponsored?YesNo
16. Are physicals required after offers of employment are made?YesNo
17. Do you have any other insurance with this insurer?YesNo
18. Has any prior coverage been declined, cancelled, or non-renewed in the last 3 years?YesNo
19. Are employee health plans provided?YesNo
20. Do any employees perform work for other businesses or subsidiaries?YesNo
21. Do you lease employees to or from other employers?YesNo
22. Do any employees predominantly work from home?YesNo
23. Any tax liens or bankruptcy within the last 5 years?YesNo
24. Any undisputed and unpaid workers’ comp premium due from you or any commonly managed or owned enterprises?YesNo
Please explain any “Yes” answers above:
By submitting, you confirm the information is true and complete to the best of your knowledge.
