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Workers Compensation Application


In order to provide the best pricing and terms for your company.

We will need the following additional information:

  1. Currently Valued Loss runs 3-5yrs ( we can assist to obtain)
  2. Historical Payroll 3-5yrs
  3. FEIN #
  4. Any Additional Entities to cover
  5. States of Operation
  6. # of FT and PT by class code
  7. Payroll by Class Code
  8. Loss Control Program "if any"
  9. Copy of Current Policy


First Name
Required
Last Name
Required
ZIP / Postal Code
Required
E-Mail Address
Required
Company Name
Required
Street Address of Business
Optional
City, State. ZIP Code
Optional
Business Type
Optional
Year Business Established
Optional
Current Insurance Provider
Optional
Additional Comments
Optional
Do you currently have insurance?
Required
Current Policy End Date
Optional
/ /
Territory
Required
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
   
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