Tell Us About You and Your Company Please fill out all fields to the best of your ability. More specifics about the business. Please enter as many details as you can. Contact Information Company Information Workers' Compensation Information Contact Information Company Name Your Full Name Your Title/Position Your Email Phone Number Address (Street, City, State, Zip) Company Details Number of Employees Tax ID / EIN Business Type Sole Proprietorship LLC Partnership Corporation Other Years in Business Estimated Total Annual Payroll Do You Outsource Your Payroll? Yes No Unsure If you have outsourced payroll, who is your vendor? Workers' Comp Details WC Experience Mod (if known) Current Carrier Hartford MEM Travelers Markel AmTrust Ace/Chubb Berkley Liberty Mutual Selective Other None (no coverage) Premium (if known) Briefly describe your business List of Class Codes from current or prior policies Do you include or exclude owners on your policy? Include Exclude Have you had any claims or lapses in coverage in the last 3 years? (If yes, provide brief detail) Do you need quotes on any other lines of coverage? SHOW SUMMARY Some required Fields are emptyPlease check the highlighted fields. Submit Previous Step Next Step
