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Workers Comp Insurance Quote
Protect your employees and your business. Get complete Workers’ Compensation coverage tailored to your operations
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Business Overview & Contact Details
Legal Business Name
*
Doing Business As (DBA) Name
Primary Contact Person
*
First
Last
Title / Position
*
Contact Phone Number
*
Email Address
*
Physical Worksite / Business Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Website URL
Entity Type
*
LLC
Corporation
Sole Proprietorship
Partnership
Non-Profit
Federal Employer Identification Number (FEIN / Tax ID)
*
Date Business Established
*
Business Operations & Payroll Details
Detailed Description of Daily Business Operations & Employee Duties
*
Total Estimated Annual Payroll ($) (Excluding Owners / Officers)
*
Total Number of Full-Time Employees
*
Total Number of Part-Time Employees
*
Do any employees work out-of-state, travel extensively, or work remotely?
*
Yes
No
Business or Employees
Do employees perform high-risk tasks?
*
Roofing / Heights
Heavy Machinery Operation
Driving / Transportation
Chemical / Hazardous Material Handling
None
Owner / Officer Coverage Options
Are Business Owners / Executive Officers to be Included or Excluded from Coverage?
*
Include Owners / Officers
Exclude Owners / Officers
If Included, list the Names, Titles, and Ownership Percentages of Included Officers
Please include each officer on a new line (e.g., Jane Smith — President — 50%).
Subcontractor & Safety Info
Do you hire Subcontractors or Independent Contractors?
*
Yes
No
Estimated Annual Subcontractor Cost ($)
Do you collect Certificates of Insurance (COIs) with Workers' Comp proof from all subcontractors prior to work starting?
Yes
No
Do you have a formal written Safety Program / Cal/OSHA Safety Plan in place?
*
Yes
No
Prior Coverage & Claims History
Do you currently have Workers' Compensation Insurance?
*
Yes
No
Current Insurance Carrier Name
Policy Expiration Date
Current Experience Modification Rating (E-Mod / EMR Number, if known)
Have you had any workplace injuries, Workers' Comp claims, or OSHA citations in the past 5 years?
*
Yes
No
If Yes, please describe the incident date(s), injury details, and total payout or claim reserve amount
Desired Coverage Limits
Employer's Liability Desired Limits
*
$100,000 / $500,000 / $100,000
$500,000 / $500,000 / $500,000
$1,000,000 / $1,000,000 / $1,000,000
Target Policy Effective Date
*
Submit
