Home > My Insurance Solutions > Worker’s Compensation > Worker’s Compensation Insurance Quote Worker’s Compensation Insurance Quote The information requested on this form will allow us to request a premium indication from multiple insurance carriers on your behalf. Should you choose to accept one of these quotes, a formal application with your signature will need to be completed. Business Name*Business Entity*LLCSole ProprietorPartnershipCorporationDBAMailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the business address the same as the mailing address?Yes / Not applicableNo, it is differentBusiness Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail* Your Name First Last Your PositionFederal ID Number# Full-time Employees# Part-time EmployeesPlease classify your employees according to their dutiesDutiesNumber of Employees i.e. how many clerical, how many warehouse, how many sales people, how many managers etc.Total annual payroll for all employees including owners/officersIf you are incorporated, are the executive officers excluded from coverage?Amount of payroll for owners/executive officers onlyAnnual gross receiptsDo you have any employment benefit plans?i.e. health insurance or retirementERISA Required?YesNoDo you have a formal written safety protocol?YesNoWhat is the best way to contact you?PhoneEmailWhat is your current Worker's Comp expiration date? Date Format: MM slash DD slash YYYY
