Workers Compensation Application
In order to provide the best pricing and terms for your company.
We will need the following additional information:
- Currently Valued Loss runs 3-5yrs ( we can assist to obtain)
- Historical Payroll 3-5yrs
- FEIN #
- Any Additional Entities to cover
- States of Operation
- # of FT and PT by class code
- Payroll by Class Code
- Loss Control Program "if any"
- Copy of Current Policy
Do you currently have insurance? *
Current Policy End Date
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
Per the terms of our
we will not resell your information to any third-party.