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800-858-1315
Workers Compensation Application
"
*
" indicates required fields
1
Who will be insured?
2
Location
3
Business Details
Hidden
Industry
Hidden
Class Code
Hidden
Agent ID
First and Last Name
*
Business Name (if applicable)
Email
*
Phone
*
Location Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Mailing Address
*
Same as previous
Street Address
City
State / Province / Region
ZIP / Postal Code
Briefly describe your business operations.
*
E.g., I sell and deliver flowers.
Entity Type
*
- Select -
Individual
Partnership
Corporation
LLC
Other
Number of Employees
- Select # of Employees -
0
1
2-5
6-10
11-25
26+
Year Business Started
*
Annual Employee Payroll (Estimated)
*
Do you hire subcontractors?
*
Yes
No
Are you currently insured for workers compensation?
*
Yes
No
Have you carried any workers compensation policies in the past 5 years?
*
Yes
No
When does your current policy expire?
*
Approximate date is OK.
Month
Day
Year
How many years have you maintainted continuous coverage without a lapse?
*
1
2
3+