Workers Compensation Insurance Quote Online

What is Workers Compensation InsuranceGeneral Liability covers bodily injury or property damage losses.

Sample QuoteThis is just a SAMPLE INSURANCE QUOTE based solely on the information provided in a SAMPLE application. This quotation may not offer all of the coverage, terms or endorsements that applicable to your business operations, or to what you requested on your actual application. Please call or email us for an explanation of the terms, coverage and endorsements that the insurer has offered, and how they may differ from what you applied.

Insurance GlossaryCovers liability incurred by a manufacturer, importer, wholesaler, retailer or distributor because of injury or property damage resulting from the use of their product.

Recent DealsInsurance markets are changing like the weather. They have their hot seasons and winter. We post our recent deals all the time so you know how good we can work for you.

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Workers Compensation Insurance Quote

Please fill out an application bellow to receive insurance quotes from multiple carriers. Your information will never be shared, leased, sold, or otherwise disclosed to any third party. For more information see Terms of Service | Privacy Policy. Coverage is available in California and Colorado only.

Full Name of Applicant / Business Name:*

Business Entity:*

List the names of all predecessor organization of the Applicant:

Principal Business Physical Address(PO BOX not allowed):*

Business Mailing Address Address(if different from above):

Contact Personal First and Last Name:*

Contact Phone Number:*

Contact Email:*

Business Website:

Year Business Established:*

How many years of experience owners have in this field?*

Federal Employer Identification Number (FEIN) or SSN:*

If your entity is controlled by, owned by, or commonly owned, affiliated or associated with any other organization, provide details:

Description of Business Operations:*

Hours of Operations:*

Are you a General Contractor with "B" license?*

Have the employees started working already, with no Workers' Compensation Insurance Coverage?*

Date you want your insurance to start*

	Duties of Employees or Classification*	# of FT Empl.	# of PT Empl.	Annual Gross Payroll*
1
2
3
4

If business owners (individuals, partners, officers, etc) want to be covered by workers comp. insurance, provide the name of each owner, duties, and annual payroll:

Check here if you currently have insurance:

Check here if you have any losses for the past 5 years:

Check here if prior coverage declined, cancelled, non-renewed in last 3 years:

Check here if you engaged in any other type of business:

Check here if you use any subcontractors or volunteers:

Do you have any employees under 16 or over 60 years of age?*

Yes No

Any work performed underground or above 15 feet?*

Yes No

Are physicals required after offers of employment are made?*

Yes No

Do you provide health insurance for your employees?*

Yes No

Do you provide benefits to all employees eligible?*

Yes No

Any employees with physical handicaps?*

Yes No

For employees who travel out of office locally, inter- or intrastate, and internationally please provide details on frequency and length of business trip:

Complete the following about your safety programs

Do you check the driving record of your employees?*

Yes No

Do employees drive their vehicles on the job?*

Yes No

Is there any athletic sponsorship?*

Yes No

Is there an aircraft or watercraft exposure?*

Yes No

Are all machines equipped with safety guards? *

Yes No

Do you maintain your facilities and equipment?*

Yes No

Do you have formal job training?*

Yes No

How often safety meetings conducted?*

Describe your formal safety program:*

How do you address housekeeping, industrial hygiene & ergonomics issues?*

Check here if you also want to recieve General Liability insurance quotes from multiple carriers

Notice to Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

	Date of Loss	Describe what happened	How much was paid?	Is the claim still open?
1				Yes No
2				Yes No
3				Yes No

Retail:
Wholesale:
Consulting:

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Workers Compensation Insurance Quote