Thank you for visiting our online quote request area.
Please complete the form below and complete as much as the information as possible in order to obtain the most effective results from our Insurance partners.

By submitting information via this form, you acknowledge that you are authorized to provide such information. The data gathered on this page will only be shared with our authorized insurance partners for the purpose of potentially securing workers’ compensation coverage for the submitter. It will not be sold or shared with any other party, and is subject to the Privacy Policies of WorkersCompensation.com

Note: Filling out this form will not result in a immediate quote on the following confirmation page - the information is first reviewed by our Partners.
Please do not fill out with innacurrate information in an attempt to see an immeditate quote.

NOTE: The following states are Monopolistic so you must Contact these States for more information about getting coverage. Ohio, North Dakota, Washingon, Wyoming

Are you: The Policy Holder Or an Agent
Company Name:
Doing Business As:
FEIN # *
Required & neccesary to provide a quote.
Years In Business -
Enter a whole number. (If New, enter 0)
Years
Contact Name: First Last
Street Address:
City:
State:
Zip:
Phone:
(Phone/Fax numbers without dashes/spaces)
Ext #:
Fax:
Email:
(! Required to obtain a quote)


Coverage

The following states are Monopolistic so you must contact the State for more information about getting coverage:

Ohio, North Dakota, Washington, Wyoming
Coverage State Number of Employees
Gross Annual Payroll

Leave out dollar signs
 $
     
Description of Business Objectives and Operational Details.
Include details such as location descriptions, tools and materials used, and amounts and types of travel.



Your Company's Workers' Compensation Policy History:
This company has never had a workers$apost compensation policy before.

OR

This company has previously had a workers ' compensation policy for years.

AND this workers compensation coverage policy is currently in force? Yes

The Existing Policy Effective Date:



The following are important required criteria for providing the most accurate & applicable quote.

Yes or No Does the applicant use uninsured subcontractors, casual labor, day labor or do they intend to cover uninsured subcontractors under this policy?
Yes or No Does the applicant or any officer own, operate, borrow or lease (1) any aircraft or (2) watercraft exceeding 25 feet in length?
Yes or No Does the applicant transport more than 5 employees per vehicle to and/or from work or jobsites on a regular basis?
Yes or No Do/Have past or present operations involve(d) storing, discharging, applying, disposing or transporting hazardous materials which in concentration are/have been determined to be dangerous to life and health?
Yes or No Any work performed underground, above 15 feet or on barges, docks or bridges?
Yes or No Is applicant engaged in any other type of business?
Yes or No Any employees under 16 or over 60 years of age?
Yes or No Has or does the applicant intend to file for bankruptcy?
Yes or No Is current coverage provided by a Professional Employer Organization (PEO) or Self Insured Fund/Trust/Group?
Yes or No Does the applicant lease or temporarily assign employees to other employers?
Yes or No Any employees with Physical Handicaps?
Yes or No Any other insurance with this Insurer?
Yes or No Any undisputed or unpaid WC Premiums due from you or other enterprise?
Yes or No Does the applicant have more than 20 people working at one location at one time?


REAL PERSON VERIFICATION - Please Select "Real Person" From the Drop Down Selection -

There are Features in this form that prevent duplicate entrys in the system.
Please only submit this form once.


Click Here To Proceed With Your Free No Obligation Insurance Quote. *Request's made after 4:00 PM PST will be recorded on the following business day.