Worker Compensation Insurance
Commercial Equipment/Inland Marine
Long Term Care
Legal Company Name (As filed with the state)
DBA Company Name
- Select -
Not For Profit
Company Phone Number
Contact Mobile Phone Number
Company FEIN or Tax ID
NAICS or SIC Code
Year Business Founded
Requested Effective Date of Policy(s)
How Many Owners In The Business?
Do You Have Work Comp Now?
In What States Do You Have Payroll? (Do not include owners) (Include State, Job, Job Description, Class Code, # of FT/PT Employees, Estimated Payroll)
Do You Have a Work Comp Modifier? (If yes, what is your current modifier?)
Do You Have Your Loss History? (Link to upload loss history)
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