Workers' Comp Application | Pogo Insurance

Let's Get Started
First, we’ll cover the basics.
What's your profession?*
What's your zip?*
Enter the zip code of your primary business location.

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What coverages are you looking for?
What are you looking for?*
- General Liability
  Helps protect your business from lawsuits or claims involving your business operations or products.
- Business Owner’s Policy
  A package that saves money by combining business property insurance and general liability insurance together.
- Professional Liability (E&O)
  Helps protect you from claims of professional negligence, even if you’ve done nothing wrong.
- Workers’ Compensation
  Helps cover medical and loss of income benefits if one of your employees gets a work-related injury or illness. It can also help with legal fees if they decide to sue.
- Business Property
  Protects the place where you do business — whether you own it, lease it, or work out of your home. Also covers personal property (like tools and equipment) used in your business.
- Business Auto
  Protects the vehicles your business owns, rents, or leases from auto liabilities. Also helps protect personal vehicles used for work-related purposes.
- Cyber Liability
  Protects your business from data breaches, leaked personal information, and identity theft when you handle sensitive customer data (even credit card information).
- Inland Marine
  Helps cover business property, assets and equipment while it’s away from your business premises, in transit, or at temporary storage locations.
- Other

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Owner Information
We need these details so we can email your quote when it's ready.
Legal Name*
First Last
Phone*
Email*
Name of business*
As it should appear on your policy. If you’re a sole proprietor, just enter your name or your trading name.
When would you like coverage to start?*
MM slash DD slash YYYY

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Where is your business located?
Primary business address*
Enter your primary business address— the place where you do most of your work— even if it's your home.

Street Address City State ZIP Code
- Use this as my mailing address
Approximately how many square feet does your business occupy at this location?*
Is the business operated out of your home?*
- Yes
- No
Any additional locations?*
This includes everywhere you or your employees work. Don’t forget warehouses, back offices or storage facilities. Also include locations for employees who work from home.
- Yes
- No

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General Liability Insurance
Does your business perform any design, construction, installation, removal, or physical repair of any property or tangible good?*
- Yes
- No
Does your business use rented or non-owned vehicles (e.g. an employee’s car) for business purposes?*
- Yes
- No
Does any owner have 50% or more common ownership in any other business?*
- Yes
- No
Choose your policy limits (Each Occurrence / Aggregate)*
Select the amount of general liability coverage you would like for each individual claim along with a total for all the claims in a given policy term. A general liability loss can include damage caused by you and/or your employees while doing business. It can also include accidents or injuries that happen at your workplace.
- $500,000 / $1,000,000
- $1,000,000 / $2,000,000
- $2,000,000 / $4,000,000
FEIN*
Workers’ comp insurance companies require an FEIN to provide a workers’ comp quote. You can apply for an FEIN online at https://sa.www4.irs.gov/modiein/individual/index.jsp Individuals/sole proprietors may use SSN if necessary.

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Professional Liability Insurance
List the qualifications of key personnel.
Name Qualifications
What percentage of your gross revenue is earned from your largest client?
For your single largest customer, anticipated over the next 12 months, please provide the total value of all goods or products sold, services rendered, operations performed, any rentals and fees. Do not include sales or excise taxes.
In what industry do the majority of your clients work?*
Do you use written contracts or statements of work for all business and services you provide?*
A written contract or statement of work is a formal document that defines the scope of work, timelines, payment terms and any other key terms and conditions.
- Always (100%)
- Most of the time (75% - 100%)
- Sometimes (50% - 75%)
- Seldom (25 - 50%)
- Never (0%)
Do you require the customer to sign-off on deliverables?*
This would indicate the customer signed, initialed and/or dated any documents that define the scope of work for the project.
- Yes
- No
- Not sure
Do you require a legal review of all contracts?*
Please confirm if you use an attorney for any changes to your standard contracts.
- Yes
- No
- Sometimes
Do your contracts have indemnification clauses in your favor?*
- Yes
- No
How much coverage do you need?
Choose your aggregate limit*
The total coverage amount for claims expenses, damages, and supplemental payments during the policy.
- $500,000
- $1,000,000
- $2,000,000
Choose your deductible*
The amount you have to pay out of pocket before your insurance company starts helping.
- $2,500
- $5,000
- $7,500
- $10,000
FEIN*
Workers’ comp insurance companies require an FEIN to provide a workers’ comp quote. You can apply for an FEIN online at https://sa.www4.irs.gov/modiein/individual/index.jsp Individuals/sole proprietors may use SSN if necessary.

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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 2
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.

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Owner/Officer Info
Do the owners wish to be included on the policy?*
Just a fancy way of asking if they want coverage or not.
- Yes
- No
*
Owner Name Owner Payroll Owner Title
*
Owner Name Owner Gender (assigned at birth) Owner DOB Beneficiary Name Beneficiary relationship

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Workers' Compensation Coverage
How much coverage do you need?
Choose your Employer's Liability Limits (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 to provide a workers’ comp quote. You can apply for an FEIN online at https://sa.www4.irs.gov/modiein/individual/index.jsp Individuals/sole proprietors may use SSN if necessary.

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Business Property Insurance
Primary business address*
Street Address City State ZIP Code
Do you own or rent this location?*
- Own
- Rent
Would you like coverage for this building?*
- Yes
- No
How much building coverage would you like?
Think of the total replacement value of the building.
Business contents coverage
Think of all the things inside this location that you’d like to cover.
Business personal property:*
The total replacement cost of your business contents. If you turned the building upside down and shook it, everything that falls out is what you'll want to include in this total.
Personal property of others:
The total replacement cost of things stored at your location that belong to your clients. Give the maximum value of property you would have at any given time.
Tenants improvements and betterments:
The total replacement value of any improvements or changes you made to your leased property. Think of any enhancements, permanent fixtures, or equipment you installed in order to do business there.

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Add location
Secondary business location
Street Address City State ZIP Code

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High-value item(s)
Would you like to cover any equipment or other high-value items on your inland marine policy? (These items are typically at least $1000 each.)*
- Yes
- No
If you bought this same item today (used), how much would it cost? After checkout, you’ll have to provide things like the year, manufacturer, and serial number.
If you bought this same item today (used), how much would it cost? After checkout, you’ll have to provide things like the year, manufacturer, and serial number.
What is it? How much is it worth?

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Additional Items
Would you like to cover any additional items in transit? (These are typically less than $1000 each.)*
- Papers and records
 (Such as fine arts, papers and drawings)
- Equipment
 (Computers, medical equipment, high-end cameras, supplies and tools)
- Software and electronic assets
 (Accounting software, lead-tracking data, policies and procedures)
- Other valuables
 (Work items that leave the business premises)
- Not really
Added up together, these items are worth around…

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Name	Qualifications

Owner Name	Owner Payroll	Owner Title

Owner Name	Owner Gender (assigned at birth)	Owner DOB	Beneficiary Name	Beneficiary relationship

What is it?	How much is it worth?

Step 1 of 24

Let's Get Started

What coverages are you looking for?

What coverages are you looking for?

What coverages are you looking for?

Business Basics

Breakdown of trades performed

Auto Repair Questions

Body Shop Questions

Employees

Financial Information

Owner Information

Where is your business located?

Coverage & Tax History

General Liability Insurance

Professional Liability Insurance

How much coverage do you need?

Cyber Liability Insurance

Employees

Employee Group 2

Additional Crew

Owner/Officer Info

Workers' Compensation Coverage

Operations

Business Property Insurance

Business contents coverage

Location Information

Add location

Inland Marine Insurance

High-value item(s)

Additional Items

Business Auto Insurance

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Driver Information

Driver 2

Driver 3

Driver 4