Interested in a Quote for Workers’ Compensation?

Fill out the application below, and we will get back to you ASAP

A. General Information

Your Name (required)

Your Email (required)

Your Phone (required)

Company Name (required)

Legal Entity

Year Business Established (required)

Mailing Address (required)

Business Phone

Website? (required)

Estimated annual sales

Insured Location (required)

Federal Employer ID Number: (required Please enter 999999999 if none)

B. COVERAGE INFORMATION

Worker's Compensation Insurance is being requested for which State(s):

Proposed Coverage Effective Date

Employer's Liability Limits (Choose One)
Standard Limits: $100,000 Each Accident, $500,000 Disease--Policy Limits, $100,000 Disease--Each EmployeeIncreased Limits (additional premium is charged) $500,000 Each Accident, $500,000 Disease--Policy Limit, $500,00 Disease--Each EmployeeCalifornia Statutory $1,000,000 Each Accident $1,000,000 Disease--Policy Limit, $1,000,000 Disease--Each Employee

Employees: Complete this section in its entirey. Be sure to account for ALL of your employees and their payroll. Or, provide a copy of your current declaration page and note any changes.

1. Solar Field Employees (including roof access)

Total Payroll

2. Electrical Ground Workers

Total Payroll

3. Clerical and Office Employees

Total Payroll

4. Sales and Marketing Employees

Total Payroll

Individuals Included/Excluded: Partners of Officers of your business can elect to be either included or excluded from Workers' Compensation benefits. If a partner or officer elects to be excluded from coverage, do not include his/her payroll in the section above. Whether electing to be included or excluded, all partner and officers must be listed below. Please include title and percentage of ownership in description box below:

Prior Coverage:
Policy Term (From/To)

Carrier

Policy #

Please list prior losses:
Loss Date

Description of Loss

Amount Paid

Open?
yesno

C. Other Information

Is applicant engaged in any other type of business?
yesno

Are Sub-Contractors used?
yesno

Any work sublet without certificates of insurance?
yesno

Is a formal safety program in operation?
yesno

Is there any volunteer or donated labor?
yesno

Do employees travel out of the country?
yesno

Any prior coverage declined/cancelled/non-renewed within the past 3 years? (not applicable in MO).
yesno

Do you lease employees to or from other employers?
yesno

Are all employees trained in how to act in the event of a robbery?
yesno

Are all employees provided with training/education on ergonomic issues?
yesno

Remarks