Workers’ Comp Quote Step 1 of 6 16% Workers' Compensation Name of Business* Type of work*Enter the type of work your business does. Number of W2 employees* Estimated annual revenue What type of work do you do-- interior or exterior?* Interior Exterior Both Is any window cleaning over one story performed?* Yes No Is any service such as asbestos or lead abatement, mold remediation, pest control, fire or flood restoration, hospital or surgical room cleaning, or crime scene clean-up performed?* Yes No Do you perform any tree trimming services?* Yes No Do you use heat treatments for bed bugs?* Yes No Do you offer any fumigation services?* Yes No What percent of sales are from termite inspections or treatment?* Employees Enter an employee group for each type of work your employees perform. Only W2 employees. Not including owners. Type of work performed*Enter the type of work this group of employees performs for your business. Number of full-time employees* Number of part-time employees Estimated payroll for this employee group*Enter the total salary amount you expect to pay this group of employees this year. Add another employee group?*Add another employee group if there's another group of employees that performs a different type of work. For example, you may own a landscaping company and most of your employees do landscaping work. But you might have employees that do clerical or outside sales, so you'll need to add an Employee Group for them. Yes No Employee Group 2Type of work performed*Enter the type of work this group of employees performs for your business. Number of full-time employees* Number of part-time employees Estimated payroll for this employee group*Enter the total salary amount you expect to pay this group of employees this year. Additional Crew Do you hire subcontractors?* Yes No Percent of labor that goes to subcontractors* What percentage of your subcontractors are uninsured?* Projected cost of uninsured subcontractors:* Any seasonal employees?* Yes No Is there any volunteer or donated labor?* Yes No Does the business require physicals after offers of employment are made?* Yes No Are there employees other than the owner or his/her relatives?* Yes No Any employees under 16 or over 60 years of age?* Yes No Owner/Officer Info Does the owner wish to be included on the policy?*The owner can only be included for workers' compensation coverage if you upgrade to a traditional workers' compensation policy. Yes No *Owner NameOwner PayrollOwner Title <b>Choose your Employer's Liability Limits</b> <br>(Each accident / Policy limit / Each employee)*Select the amount of coverage you would like for each individual claim, along with the total limit for all claims in a given policy term, for each employee. $100,000/$500,000/$100,000 $500,000/$500,000/$500,000 $1,000,000/$1,000,000/$1,000,000 Do any of your contracts require a waiver of subrogation?* Yes No I'm not sure FEIN*Workers’ comp insurance companies require an FEIN or SSN to provide a workers’ comp quote. You can apply for an FEIN online at https://sa.www4.irs.gov/modiein/individual/index.jsp Operations Do any of the following apply to your business?* Work is performed underground or above 15 feet. The business owns, operates or leases aircraft or watercraft The business has past, present, or discontinued operations involving storing, treating, discharging, applying, disposing, or transporting of hazardous material (e.g. landfills, wastes, fuel tanks, etc) Work is performed on barges, vessels, docks, or bridges over water. The business provides group transportation. The business sponsors an athletic team. The business has an employment leasing or Professional Employer Organization (PEO) contract. None of the above What is the max height you work at?* What % of your operations, if any, involve roofing?* Does anyone from the business:* Have any physical handicaps? Travel out of state for business? Work predominantly from home? Engage in another type of business? Perform work for other businesses or subsidiaries? Not have citizenship or the legal right to work in the U.S.? Implement a written safety program? None of the above Is there a workers' comp policy in effect for the other business?* Yes No Does the business engage in any of the following operations?* Nuclear energy Railroads, ship building, underground mining, or commercial airlines Oil and gas drilling, refining or manufacturing Manufacturing, storage, or transportation of fireworks, nitrogen-glycerin, or other explosive substances or devices Asbestos abatement, manufacturing or distribution Explosives manufacturers, haulers, or distributors Jones Act, Defense Base Act, Outer Continental Shelf Lands Act Demolition and blasting 24 hour operations None of the above Is a written safety program in operation?* Yes No Coverage & Tax History Tell us a little bit about your current insurance coverage.Do you currently have a workers' comp policy in effect?* Yes No Any prior coverage declined / cancelled / non-renewed in the last three (3) years?* Yes No Please explain:*Any undisputed or unpaid workers’ comp premium (payments) due from you or any commonly managed or owned companies?* Yes No Please explain:Does your business have a health insurance plan in effect?* Yes No Any tax liens or bankruptcy within the last five (5) years?* Yes No
