What is your first name?
What is your last name?
What is your preferred phone number?
What is your email address?
What is your job title?
What is address of your business?
Is the above address also your business's mailing address?
What is the mailing address for your business?
Business Information
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What is your company's legal name?
Does your company have a trade name (DBA)?
What is your company's trade name (DBA)?
What is your company's website address? (Include https://)
Please provide a detailed description of your business.
Does your business have multiple locations?
Please enter the addresses of your additional locations.
Please enter your federal ID number?
Please enter your state ID number, if applicable?
How many years has your company been in business?
What is the approximate inception date of the business?
MM slash DD slash YYYY
What type of legal entity is your company structured under?
Does the company provide health insurance for employee(s)?
What is the name of the group health insurance carrier?
Do you provide disability insurance for your employee(s)?
What is the name of your current Workers' Compensation Carrier?
What is the expiration date of your current Workers' Compensation policy?
MM slash DD slash YYYY
What date would you like new Workers' Compensation coverage to be effective?
MM slash DD slash YYYY
End Business Information Section
Employee Information
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Please select the state(s) where your company has employees working, including telecommuters. (Select all that apply)
Alabama Employee Information
How many different employee job types does your company have in Alabama?
Employee Type 1 - Alabama
Please enter a brief job description for the first employee type.
Please enter the class code for this employee type as listed on your current Workers' Compensation policy.
How many full time employees have this job description?
How many part time employees have this job description?
What is the estimated payroll for the employees with this job description?
What is the rate being charged by your current carrier for employees with this job description?
What is the estimated annual premium with your current carrier for employees with this job description?
Employee Type 2 - Alabama
Please enter a brief job description for the second employee type.
Please enter the class code for this employee type as listed on your current Workers' Compensation policy.
How many full time employees have this job description?
How many part time employees have this job description?
What is the estimated payroll for the employees with this job description?
What is the rate being charged by your current carrier for employees with this job description?
What is the estimated annual premium with your current carrier for employees with this job description?
Employee Type 3 - Alabama
Please enter a brief job description for the third employee type.
Please enter the class code for this employee type as listed on your current Workers' Compensation policy.
How many full time employees have this job description?
How many part time employees have this job description?
What is the estimated payroll for the employees with this job description?
What is the rate being charged by your current carrier for employees with this job description?
What is the estimated annual premium with your current carrier for employees with this job description?
Employee Type 4 - Alabama
Please enter a brief job description for the fourth employee type.
Please enter the class code for this employee type as listed on your current Workers' Compensation policy.
How many full time employees have this job description?
How many part time employees have this job description?
What is the estimated payroll for the employees with this job description?
What is the rate being charged by your current carrier for employees with this job description?
What is the estimated annual premium with your current carrier for employees with this job description?
Additional Employee Information
Please provide details of the other employee job types in this state.
Has your employee payroll changed dramatically over the course of the last 12 months?
What is the projected payroll for the next 12 months?
Please provide a brief description of the reason for the change in payroll. (Ie. New employees, etc.)
Do employees use their personal vehicles for business purposes?
End Employee Information
Coverage for Partners, Officers, or Relatives
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Do you want to INCLUDE/EXCLUDE Partners, Officers, Owners, or Relatives from workers compensation coverage?
Please select the individuals you would like to EXCLUDE from workers compensation coverage.
Please select the individuals you would like to INCLUDE in workers compensation coverage.
Please enter information about the partner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the partner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the officer(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the officer(s) to be INCLUDED in workers compensation coverage.
Please enter information about the LLC Member(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the LLC Member(s) to be INCLUDED in workers compensation coverage.
Please enter information about the Owner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the Owner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the relative(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the relative(s) to be INCLUDED in workers compensation coverage.
End Coverage for Partners, Officers or Relatives
Subcontractor Utilization
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Does your business utilize subcontractors?
What is the approximate percentage of work that is done by subcontractors? (Ex. 25%)
Is any work sublet without a certificate of insurance from the contractor?
What is the payroll for the subcontractors you do not collect certificates of insurance from?
End Subcontractor Utilization
Loss History
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Has your company had any workers compensation claims in the past four years?
Please enter the requested information for all claims in the previous four years.
End Loss History
Documents and Comments
Please use this field to upload any relevant insurance documents. (ie. Current Declarations Pages, etc...)
Please enter any additional remarks or advise if there is anything else we can do for you in the space below.
- 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 this box 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.
