Workers Compensation Application Entry Date Date Format: MM slash DD slash YYYY IndustryClassControllling AgentBriefly describe your business operations.*E.g., I sell and deliver flowers.Name* First Last Email* Phone*Business Name (if applicable)Entity Type*- Select -IndividualPartnershipCorporationLLCOtherNumber of Employees- Select # of Employees -012-56-1011-2526+Year Business Started*Annual Employee Payroll (Estimated)*Do you hire subcontractors?*YesNo LocationAddress* Street Address City State / Province / Region ZIP / Postal Code CoverageAre you currently insured for workers compensation?*YesNoHave you carried any workers compensation policies in the past 5 years?*YesNoWhen does your current policy expire?*Approximate date is OK. MM DD YYYY How many years have you maintainted continuous coverage without a lapse?*123+In addition to Workers Compensation, please indicate any other quotes to include. Commercial Auto General Liability Professional Liability Property Umbrella Questions? Call 800-311-3081
