Request A Quote

Your Information

1. Your Name(required)
2. Email(valid email required)
3. Phone(required)
4. Fax
5. Website
6. Company Name(required)
7. Street Address(required)
8. Street Address
9. City(required)
10. State(required)
11. ZIP(required)
12. Comments / Message

Corporate Information

1. Correct Corporate Name
2. DBA Name
3. Corporate Address
4. Corporate City
5. Corporate State
6. Corporate ZIP
7. Corporate Email Address(valid email required)
8. Physical Location of Employees Worksite
9. Corporate Structure
10. Date Business Started
11. Federal ID#
12. Corporate Phone
13. Corporate Fax
14. Phyiscal Phone
15. Physical Fax
16. Current Unemployment Account #
17. Owner #1 Name
18. Owner #1 Title
19. Owner #1 SS#
20. Owner #1 Date of Birth
21. Owner #1 Address
22. Owner #1 Phone
23. Owner #1 % of Ownership
24. Owner #2 Name
25. Owner #2 Title
26. Owner #2 SS#
27. Owner #2 Date of Birth
28. Owner #2 Address
29. Owner #2 Phone
30. Owner #2 % of Ownership
31. Owner #3 Name
32. Owner #3 Title
33. Owner #3 SS#
34. Owner #3 Date of Birth
35. Owner #3 Address
36. Owner #3 Phone
37. Owner #3 % of Ownership
38. Prior Worker's Comp Carriers
39. Loss Runs from Prior Carriers
40. Description of Operations
41. Do you own, operate or lease aircraft / water craft?
42. Yes No
43. Do you work with hazardous materials?
44. Yes No
45. Any work performed underground or above 15 feet?
46. Yes No
47. Any work performed on barges, vessels, docks, bridges over water?
48. Yes No
49. Is applicant involed in any other type of business?
50. Yes No
51. If yes to other business, please explain
52. Are subcontractors used?
53. Yes No
54. Any work sublet without certification of insurance?
55. Yes No
56. Do you have a formal written safety program?
57. Yes No
58. Is there a drug free workplace program in place?
59. Yes No
60. Any employees under 16 or over 60?
61. Yes No
62. Any part time or seasonal employees?
63. Yes No
64. Any volunteer or donated labor?
66. Any employees with physical handicaps?
67. Yes No
68. Do employees travel out of state?
69. Yes No
70. Are atheltic teams sponsored?
71. Yes No
72. Are physicals required after employment offers made?
73. Yes No
74. Any other insurance with this carrier (LWCC)?
75. Yes No
76. Any prior coverage declined/cancelled/non-renewed in past 3 years?
77. Yes No
78. If yes to above (prior coverage) please explain
79. Are employee health plans provided?
80. Yes No
81. Do you lease employees to other employers?
82. Yes No
83. Do any employees predominately work at home?
84. Yes No
85. Any group transportation provided?
86. Yes No
87. Is there an interchange with any other business / subsidiary?
88. Yes No
89. # of employees(required)
90. # of hours worked per week(required)
91. Gross Wages(required)
92. New Field
93. New Field
94. New Field
95. New Field
96. New Field
97. New Field
98. New Field
99. New Field
100. New Field
101. New Field
102. New Field