Workers' Compensation Insurance Form

Company Contact 1 - First Name
What is your first name?
What is your last name? **
What is your last name? *
What is your preferred phone number? **
What is your preferred phone number? *
What is your email address? **
What is your email address? *
Company Contact Title
What is your job title?
What is address of your business? **
What is address of your business? *

Street Address Address Line 2 City State ZIP Code
Business Mailing Address?
Is the above address also your business's mailing address?
- Yes
- No
Business Mailing Address
What is the mailing address for your business?

Street Address Address Line 2 City State ZIP Code
Business Information
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What is your company's legal name? **
What is your company's legal name? *
Trade Name?
Does your company have a trade name (DBA)?
- Yes
- No
Company Trade Name
What is your company's trade name (DBA)?
Company Website
What is your company's website address? (Include https://)
Please provide a detailed description of your business. **
Please provide a detailed description of your business. *
Multiple Locations?
Does your business have multiple locations?
- Yes
- No
Additional Locations
Please enter the addresses of your additional locations.
Street City State Zip Code
Company Federal ID
Please enter your federal ID number?
Company State ID
Please enter your state ID number, if applicable?
Years in Business
How many years has your company been in business?
Business Inception Date
What is the approximate inception date of the business?
MM slash DD slash YYYY
Legal Entity Type
What type of legal entity is your company structured under?
Employee Health Insurance?
Does the company provide health insurance for employee(s)?
- Yes
- No
Group Health Carrier Name?
What is the name of the group health insurance carrier?
Disability for Employees?
Do you provide disability insurance for your employee(s)?
- Yes
- No
Current Workers' Comp Carrier
What is the name of your current Workers' Compensation Carrier?
Workers' Compensation Current Expiration Date
What is the expiration date of your current Workers' Compensation policy?
MM slash DD slash YYYY
Workers' Compensation Requested Effective Date
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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Employee 1 - Job Description
Please enter a brief job description for the first employee type.
Employee 1 - Class code
Please enter the class code for this employee type as listed on your current Workers' Compensation policy.
Employee 1 - Full Time Headcount
How many full time employees have this job description?
Employee 1 - Part Time Headcount
How many part time employees have this job description?
Employee 1 - Estimated Payroll
What is the estimated payroll for the employees with this job description?
Employee 1 - Workers Compensation Rate
What is the rate being charged by your current carrier for employees with this job description?
Employee 1 - Estimated Annual Premium
What is the estimated annual premium with your current carrier for employees with this job description?
Second Employee Type?
Is there a second job description to enter?
- Yes
- No
Employee 2 - Job Description
Please enter a brief job description for the second employee type.
Employee 2 - Class code
Please enter the class code for this employee type as listed on your current Workers' Compensation policy.
Employee 2 - Full Time Headcount
How many full time employees have this job description?
Employee 2 - Part Time Headcount
How many part time employees have this job description?
Employee 2 - Estimated Payroll
What is the estimated payroll for the employees with this job description?
Employee 2 - Workers Compensation Rate
What is the rate being charged by your current carrier for employees with this job description?
Employee 2 - Estimated Annual Premium
What is the estimated annual premium with your current carrier for employees with this job description?
Third Employee Type?
Is there a third job description to enter?
- Yes
- No
Employee 3 - Job Description
Please enter a brief job description for the third employee type.
Employee 3 - Class code
Please enter the class code for this employee type as listed on your current Workers' Compensation policy.
Employee 3 - Full Time Headcount
How many full time employees have this job description?
Employee 3 - Part Time Headcount
How many part time employees have this job description?
Employee 3 - Estimated Payroll
What is the estimated payroll for the employees with this job description?
Employee 3 - Workers Compensation Rate
What is the rate being charged by your current carrier for employees with this job description?
Employee 3 - Estimated Annual Premium
What is the estimated annual premium with your current carrier for employees with this job description?
Fourth Employee Type?
Is there a fourth job description to enter?
- Yes
- No
Employee 4 - Job Description
Please enter a brief job description for the fourth employee type.
Employee 4 - Class code
Please enter the class code for this employee type as listed on your current Workers' Compensation policy.
Employee 4 - Full Time Headcount
How many full time employees have this job description?
Employee 4 - Part Time Headcount
How many part time employees have this job description?
Employee 4 - Estimated Payroll
What is the estimated payroll for the employees with this job description?
Employee 4 - Workers Compensation Rate
What is the rate being charged by your current carrier for employees with this job description?
Employee 4 - Estimated Annual Premium
What is the estimated annual premium with your current carrier for employees with this job description?
Has your employee payroll changed dramatically over the course of the last 12 months?
Has your employee payroll changed dramatically over the course of the last 12 months?
- Yes
- No
Please provide a brief description of the reason for the change in payroll.
Please provide a brief description of the reason for the change in payroll. (Ie. New employees, etc.)
Do you allow employees to use your personal vehicle for business use?
Do you allow employees to use your personal vehicle for business use?
- Yes
- No
What is the projected payroll for the next 12 months?
What is the projected payroll for the next 12 months?
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?
Do you want to INCLUDE/EXCLUDE Partners, Officers, Owners, or Relatives from workers compensation coverage?
- Include
- Exclude
Please select the individuals you would like to EXCLUDE from workers compensation coverage.
Please select the individuals you would like to EXCLUDE from workers compensation coverage.
- Partner(s)
- Officer(s)
- LLC Member(s)
- Owner(s)
- Relative(s)
Please select the individuals you would like to INCLUDE in workers compensation coverage.
Please select the individuals you would like to INCLUDE in workers compensation coverage.
- Partner(s)
- Officer(s)
- LLC Member(s)
- Owner(s)
- Relative(s)
Please enter information about the partner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the partner(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the partner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the partner(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the officer(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the officer(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the officer(s) to be INCLUDED in workers compensation coverage.
Please enter information about the officer(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
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 EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the LLC Member(s) to be INCLUDED in workers compensation coverage.
Please enter information about the LLC Member(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the Owner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the Owner(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the Owner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the Owner(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the relative(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the relative(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the relative(s) to be INCLUDED in workers compensation coverage.
Please enter information about the relative(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
End Coverage for Partners, Officers or Relatives
Subcontractor Utilization
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Subcontractor Utilization?
Does your business utilize subcontractors?
- Yes
- No
Subcontractor Percentage of Work
What is the approximate percentage of work that is done by subcontractors? (Ex. 25%)
Subcontractor Certificates of Insurance
Is any work sublet without a certificate of insurance from the contractor?
- Yes
- No
- Not sure
Subcontractor Payroll without Certificates of Insurance
What is the payroll for the subcontractors you do not collect certificates of insurance from?
End Subcontractor Utilization
Loss History
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Claims History?
Has your company had any workers compensation claims in the past four years?
- Yes
- No
Claims Information
Please enter the requested information for all claims in the previous four years.
Year Carrier Policy # Description Amount Paid
End Loss History
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.
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Alison Chirinos

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Street	City	State	Zip Code

Full Name	Title	Duties	Date of Birth	Annual Payroll	Ownership %

Full Name	Title	Duties	Date of Birth	Annual Payroll	Ownership %

Full Name	Title	Duties	Date of Birth	Annual Payroll	Ownership %

Workers' Compensation Insurance Form

Business Information

End Business Information Section

Employee Information

End Employee Information

Coverage for Partners, Officers, or Relatives

End Coverage for Partners, Officers or Relatives

Subcontractor Utilization

End Subcontractor Utilization

Loss History

End Loss History

Documents and Comments

Alison Chirinos

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