Domestic Workers' Compensation Insurance Form

Company Contact 1 - First Name*

What is your first name? *

Company Contact 1 - Last Name*

What is your last name? *

Company Contact Role*

What is your role? *

Company Contact - Email*

What is your email address? *

Company Phone*

What is your preferred phone number? *

Employer Information

What date would you like this coverage to commence? **

What date would you like this coverage to commence? *

What is your mailing address?

Street Address Address Line 2 City State ZIP Code

Is this address also where the employee(s) works?

Yes
No
Yes, plus other(s)

How many work locations are there? (Enter a numeric, i.e. 2) **

How many work locations are there? (Enter a numeric, i.e. 2) *

Please enter all work locations.

Street	City	State	Zip code

Where do the employee(s) primarily work?

Please enter your federal ID number (EIN)?

Please enter your state ID number, if applicable?

What type of legal entity are your employee(s) structured under?

Please enter the legal entity type your employees are structured under.

Employee Information

How many domestic employees do you have? (Maximum number is 5) **

How many domestic employees do you have? (Maximum number is 5) *

Please enter a number from 1 to 5.

Please enter the employee information below.

First Name	Estimated Wkly Hours	Estimated Annual Compensation	Description of Duties	Employed Since (YYYY)

Do you allow employees to use your personal vehicle(s)?

Yes
No

Claims/Loss History

Are you aware of any factors or circumstances which may result in any losses, claims or suits for workers compensation or employers liability being made against you or a resident family member? **

Are you aware of any factors or circumstances which may result in any losses, claims or suits for workers compensation or employers liability being made against you or a resident family member? *

Yes
No

Have there been any workers compensation or employment liability losses in the last 5 years? **

Have there been any workers compensation or employment liability losses in the last 5 years? *

Yes
No

Documents and Comments

Relevant Workers Comp Documents

Please use this field to upload any relevant insurance documents. (ie. Current Declarations Pages, etc...)

Drop files here or

Max. file size: 128 MB.

Additional Remarks

Please enter any additional remarks or advise if there is anything else we can do for you in the space below.

Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

I agree *

Domestic Workers' Compensation Insurance Form

Employer Information

Employee Information

Claims/Loss History

Documents and Comments

Brian Cook

RiskRevu^TM Newsletter

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Domestic Workers' Compensation Insurance Form

Employer Information

Employee Information

Claims/Loss History

Documents and Comments

Brian Cook

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter