Submit Workers' Compensation Risk

Insured Information

Insured Name

DBA (if applicable)

Contact Name

Contact Email

Contact Phone

Business Website

Years in Business

FEIN/Tax ID

Mailing Address

City

State

ZIP Code

Type of Business

Business Description

Coverage Information

Requested Effective Date

Expiration Date

Current Carrier

Current Premium ($)

Experience Modifier

Deductible Requested

States Where Coverage is Needed

USL&H Coverage Needed?

Payroll Information

Total Number of Employees

Number of Full-Time Employees

Number of Part-Time Employees

Number of 1099 Contractors

Payroll by Classification

Classification 1

Class Code

Classification Description

Number of Employees

Annual Payroll ($)

Claims History

Number of Claims in Last 5 Years

Total Incurred Amount ($)

Largest Claim Amount ($)

Number of Open Claims

Safety Program

Do you have a written safety program?

Do you have a return to work program?

Do you conduct drug testing?

Do you conduct background checks?

Document Upload

Upload Loss Runs (5 years)

Drag and drop your loss runs here or click to browse

Upload Experience Modification Worksheet

Drag and drop your experience mod worksheet here or click to browse

Upload ACORD Forms

Drag and drop your ACORD forms here or click to browse

Upload Current Declarations Page

Drag and drop your declarations page here or click to browse

Upload Safety Program (if available)

Drag and drop your safety program document here or click to browse

Upload Additional Documents

Drag and drop additional documents here or click to browse