Workers’ Compensation Quote Application

Looking for a Workers’ Compensation Quote?  You can apply for Workers’ Compensation by completing the following application.  One of our agents will be with you shortly to discuss your insurance quote.

We promise not to use your information for anything other than to determine your Worker’s Compensation Insurance quote. Your information will not be sold to any third party.

Applicant Name:
Enter the business's name, or if a sole proprietor, your name.
Office Phone:
Enter the business's office phone number.
Mobile Phone:
Enter your mobile phone number.
Email Address:
Enter a valid business email address.
Website Address:
Enter your business's website address.
Business's FEIN or your SSN:
Enter your business's federal employer identification number OR your social security number if a sole proprietor.
Type of Entity:
 Sole Proprietor Partnership Corporation "S" CorporationEnter the the business's entity type.
Street Address
Street Address Line 2
City
State
Zip Code
Business Description
Briefly describe the nature of your business.
Partners and Officers to be Included/Excluded

Please include this information:

NAME
DOB
TITLE
OWNERSHIP %
SSN, and
JOB DUTIES
Rating Information

Separately indicate the number of part-time and full-time employees to be covered. Include location, pay rates, and a description of each employee's duties.
Prior Carrier Information:

1.) Worker's compensation losses/claims in the last 4 years.

2.) Prior or current worker's compensation carrier, if applicable.

3.) Premium paid on prior/current policy.

If you currently have a policy, please fax us the front page of your current policy: (703) 527-7207
Is any work performed underground?
 Yes No
Is any work performed at least 15 feet above ground?
 Yes No
Subcontractor Use:
If subcontractors are used, indicate the percentage of work that is subcontracted out.
Written Safety Program?
 Yes NoIs a written safety program in operation at your business?
Are any employees under 16 years of age?
 Yes No
Are any employees over 60 years of age?
 Yes No
Tax Liens:
 Yes NoAny Tax Liens within the last five years?
Bankruptcy:
 Yes NoHas the business filed for bankruptcy in the last five years?
Owner's Experience I:

Please describe the number of years of the owner's experience with full responsibility for management in this industry.
Owner's Experience II:

Please describe the number of years of the owner's experience in the industry, management or non-management.