Business Owners-Worker’s Compensation Policy

Requesting for
Business Owner’s InsuranceWorkmen’s Comp InsuranceBoth

    Contact Information

    Please fill in the information below

    Once received, one of our Representatives will contact you within 24-48 hours. We appreciate the opportunity to serve you.

    * Required Fields









    Business Owners General Information

    Purpose of Application

    Desired Effective Date

    Year Business was established or acquired from previous owner

    Type of Business Entity
    Individual

    Corp
    Other

    Legal Business Name

    If Other. D/B/A Name

    Federal Tax ID

    Expected Annual Gross Sales

    Physical Primary Location

    Business Owners Building Information

    Year Building Built

    Owner or Tenant?
    OwnerTennant

    Building Coverage Limit (Building Owners Only)

    Sq. Footage of Building*

    Sq. Footage of Office*

    Sq. Footage of Office*

    Personal Property Coverage*
    (Amount needed to replace contents)

    Personal Property Deductible Option
    $500 (Most Common)$1000
    General Liability Limit
    1,000,000/2,000,000Other

    Full Time Employees

    Part Time Employees

    Type of Outside Construction
    BrickStuccoOther

    Building Sprinklered
    Yes

    No
    Fire Alarm
    NoneLocalCentral
    Buglar Alarm Type
    NoneLocalCentral
    Number of Stories

    Basement
    YesNo
    Year Updates Were Completed (if building over 25 years old)

    Additional Interest: If you need anyone listed as an additional insured or Loss Payee, please list below.

    Reason

    Name of Interest

    Street Address

    City

    State, Zip

    For verification purposes, please type in the numbers and letters that you see below then press the Send Request button

      Contact Information

      Please fill in the information below

      Once received, one of our Representatives will contact you within 24-48 hours. We appreciate the opportunity to serve you.

      * Required Fields









      Worker’s Compensation Information

      Full time Employees

      Part time Employees

      Umbrella Coverage

      Umbrella Coverage? YesNo
      Limit 1m2m
      Include Doctor YesNo

      Annual payroll of Doctor

      Payroll Amount for Massage Therapists

      Annual Expected Payroll

      Claims History YesNo

      If Yes, Please Specify...

      Has Prior Coverage ever been cancelled? YesNo

      If Yes, Please Specify...

      Business/Entity Name

      Physical Primary Location

      TAX ID Number

      For verification purposes, please type in the numbers and letters that you see below then press the Send Request button

        Contact Information

        Please fill in the information below

        Once received, one of our Representatives will contact you within 24-48 hours. We appreciate the opportunity to serve you.

        * Required Fields









        Business Owners General Information

        Purpose of Application

        Desired Effective Date

        Year Business was established or acquired from previous owner

        Type of Business Entity
        Individual

        Corp
        Other

        Legal Business Name

        If Other. D/B/A Name

        Federal Tax ID

        Expected Annual Gross Sales

        Physical Primary Location

        Business Owners Building Information

        Year Building Built

        Owner or Tenant?
        OwnerTennant

        Building Coverage Limit (Building Owners Only)

        Sq. Footage of Building*

        Sq. Footage of Office*

        Sq. Footage of Office*

        Personal Property Coverage*
        (Amount needed to replace contents)

        Personal Property Deductible Option
        $500 (Most Common)$1000
        General Liability Limit
        1,000,000/2,000,000Other

        Full Time Employees

        Part Time Employees

        Type of Outside Construction
        BrickStuccoOther

        Building Sprinklered
        Yes

        No
        Fire Alarm
        NoneLocalCentral
        Buglar Alarm Type
        NoneLocalCentral
        Number of Stories

        Basement
        YesNo
        Year Updates Were Completed (if building over 25 years old)

        Additional Interest: If you need anyone listed as an additional insured or Loss Payee, please list below.

        Reason

        Name of Interest

        Street Address

        City

        State, Zip

        Worker’s Compensation Information

        Full time Employees

        Part time Employees

        Umbrella Coverage

        Umbrella Coverage? YesNo
        Limit 1m2m
        Include Doctor YesNo

        Annual payroll of Doctor

        Payroll Amount for Massage Therapists

        Annual Expected Payroll

        Claims History YesNo

        If Yes, Please Specify...

        Has Prior Coverage ever been cancelled? YesNo

        If Yes, Please Specify...

        Business/Entity Name

        Physical Primary Location

        TAX ID Number

        For verification purposes, please type in the numbers and letters that you see below then press the Send Request button