Please offer the full, legal name of your firm.
Doing Business As (if applicable)
FEIN# (Federal Employer ID Number)
Your FEIN or TAX ID # will be 9 digits.
Limited Liability Company (LLC)
Year Business Began
Are mailing & physical addresses the same?
Any prior coverage?
When will you be opening doors?
Please estimate a date
Who is your current insurance carrier?
How many years?
Upload Policy Here
Please upload a copy of your current policy if you have one on file. We do not need the entire policy. We would just need to first few pages, commonly labeled "declarations" or "information page" ... the pages we need will list the insured name & address, policy period, coverage, classification & rating schedule.
Currently Valued Loss Runs (Prior 4 years)
For however many years you've been in business, your insurance carrier(s) have maintained documented proof of workers comp related claims & losses throughout any given policy period. Any new carrier quoting your workers comp requires 4 years of currently valued loss runs (valued within 60 days of your current expiration date). If you are a new business venture, loss history is not mandated. If you would prefer signing a 'loss run request,' we can send this request to your insurance company and they can send us your loss history directly.
A workers comp class code is a 4-digit number that identifies an employee's classification of work. Whether they are roofers or clerical workers, each class code represents a specific level of risk for the insurance company.
# of full time employees
# of part time employees
Payroll is estimated. It's to your advantage to overestimate because your company will be audited at the end of each policy term (unless you have automatic payroll deductions).
Is a formal written safety program in operation?
Safety manual? Monthly meetings?
Any seasonal employees?
Do employees travel out of state?
Any volunteer or donated labor?
Any employees under 16 or over 60?
Are employee health plans provided?
Do any employees perform work for other businesses?
Do any employees predominantly work from home?
Any bankruptcy or tax lien within the last 5 years?
Any employees with physical handicaps?
Any work preformed underground or above 15 feet?
Any prior coverage declined, cancelled or non-renewed in the last 3 years?
Hours of operation?
Any group transportation provided?
Please explain "yes" responses in greater detail.
Who holds stake in the company? In the state of CA, if you own more than 15% of a business, you have the option to exclude yourself from coverage. If you own less than 15%, you must be included in the annual payroll estimate.
Is there anything else you'd like to mention about your company, employees, operations, etc.?
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