Get Your Free Quote Now


Get a Quote


Please list the type of Corporation you are
(S-Corp, C-Corp, LLC, Sole Proprietor, Individual Non-Profit etc.)
Company Contact:
Decision Maker:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:

Company Name


Please provide as much information about your business as possible, so we have a good understanding of what you do.

If you're in the Construction Industry, do you have a General Contractors License and what percentage of work do you subcontract out? Please be specific about the work you do. Remember each job has a different class code and rate. (Example: Painting, drywall, rough framing, cabinet and trim works all have different workers comp codes and ALL have different rates and a handyman is not a class.)

If you're in the transportation business what is the average daily radius of operation? What do you haul? Do you travel out-of-state? Are you looking to cover owner operators?

Number of W-2 Employees excluding owners:
Number of 1099's issued to sub contractors annually?
Do you get proof of workers comp if you sub work out?
Annual Payroll of W-2 Employees:
Annual Payroll of all 1099 Subs:
Do you want to exclude coverage for Owners or Officers?
Do you currently use a Payroll service or Leasing Company?
If yes Who?
Years in business under current name or Tax Id Number?
Tax ID# or SSC#:
Are you looking for coverage for a short term project?
Do you need General Liability?
Current Workers Compensation Carrier and expiration date:
Current Annual Premium:

Misc Information to help the agent:

1. If you NEVER had workers compensation and have been in business over 1 year please explain briefly why you need coverage now?

2. If you had coverage when and why did it lapse and do you owe money?

3. If you currently have workers compensation coverage please look at your current policy and summarize your workers compensation classification (Example clerical 8810). Please list your class code, payroll for each code, price for each code, experience modification factor, and any losses.

4. If you are looking to cover a short term project how long is the project going to last and when do you need a workers compensation certificate issued? We have good programs for short term projects?

Enter the code as it is shown*

Information for State Workers Compensation Insurance