This field is hidden when viewing the formSalespersonCorporation Name / Legal Entity NameBusiness Name (DBA)Email PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Description of BusinessOwner(s) / Officer(s)NameOwnership Percentage Add RemoveUse the + button on the right side to add a row for each owner/officer.Current Insurance ProviderCurrent Policy Renewal Date MM slash DD slash YYYY What type of business? Individual Sole Proprietor Corporation LLC Other Are owners or officers included in workers compensation coverage? Yes No Owner/Officer Information for Workers compensationNameClass Code UsedAnnual Salary Add RemoveUse the + button on the right side to add a row for each owner/officer.*** If Owners and Officers ARE Included above, do NOT include this payroll in the payroll BELOWFederal Tax ID NumberYears in BusinessYears Current OwnershipYears With EmployeesEmployer’s Liability Limit 100K/100K/500K 500K/500K/500K 1Mil/1Mil/1Mil Use the + button on the right side to add a row for each class code.Class CodeDescriptionAnnual Est. PayrollFull-Time EmployeesPart-Time Employees Add RemoveUse the + button on the right side to add a row for each class code.Do you contribute at least 50% of the employee's cost of medical benefits? None All Employees Full-Time Employees Only Management Employees Only What is the employees waiting period before benefits take effect? None 30 Days or Less 60 Days 90 Days or More Please check all that apply below for policy discounts Formal Job Description Forklift Certification Job Rotation Full-Time Safety Director Direct Management Oversight Lock-Out/Tag-Out Procedures Ergonomic Workstations Post-Offer Employment Physical Job Site / Work Place Safety Inspection Early Return To Work Duties Formal, Recurring Safety Training Mandatory Drug Testing First Aid Training Safety Meetings Require Use of Personal Protective Equipment Investigate Accidents Driver MVR Pulls Lifting Training Use of Designated Medical Providers Enforced Use of Machine Guarding To expedite your Proposal, we need the following for all risks:Copy of Work Comp policy Drop files here or Select files Max. file size: 128 MB. Copy of Loss Runs Drop files here or Select files Max. file size: 128 MB. Consent(Required) I Agree to the Privacy Policy, Terms of Service, and to Receive Communications.
