Minimum Premium Workers’ Comp Quote Step 1 of 18 5% Let's Get Started First, we’ll cover the basics. Profession*Select0042 Landscaping0917 Residential Cleaning2585 Carpet Cleaning2802 Carpentry Shop Only3040 Ornamental Ironworks3365 Welding3724 Mechanical/Equipment Erection5020 Ceiling Installation5022 Masonry NOC5102 Door/Window Installation5183 Plumbing5188 Automatic Sprinkler Installation5190 Electrical Wiring within buildings5191 Office machine installation5215 Concrete work5221 Concrete work - driveways/pathways5223 Swimming Pool Installation5348 Tile Work5445 Drywall Installation5467 Glazier5474 Painting5535 Sheet Metal Installation5537 HVAC5539 Metal Building Erection6217 Excavation6400 Fence Erection7600 Satellite TV Installation7605 Burglar & fire Alarm installation7611 Cable TV Installation8017 Store NOC8380 Auto Service and Repair8393 Auto Body Repair8602 Surveyor8720 Inspection of Risks for Insurance8742 Salesperson8803 Auditor/computer programmer8810 Clerical8831 Pet Groomer8835 Home Health Care9014 Commercial Janitorial Services9082 Restaurants9083 Restaurants (fast foods)9102 Park NOC9519 Household appliance installation9521 House furnishing installation9586 Barber ShopOtherEnter your profession* Business Structure* Sole Proprietor Partnership LLC S-Corp Other Enter business structure:* How many employees do you have?<br><i>(not including owners)</i> Include full-time, part-time and temporary W2 employees. Do not include owners or subcontractors (1099). Additional Coverages Add another coverage to your quote? General LiabilityHelps protect your business from lawsuits or claims involving your business operations or products. Business PropertyProtects 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 Owner’s PolicyA package that saves money by combining business property insurance and general liability insurance together. Business AutoProtects the vehicles your business owns, rents, or leases from auto liabilities. Also helps protect personal vehicles used for work-related purposes. Inland MarineHelps cover business property, assets and equipment while it’s away from you business premise, in transit, or at temporary storage locations. No Thanks Business BasicsHow many years have you been in business?*The number of years this business has been operating under current ownership. I’m new in business 1 year 2 years 3 years 4 or more years Please tell us what your business does:*This includes the services you provide, the goods you sell, or the products you manufacture.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 Who is this quote for? We need these details in order to give you a quote.Owner's Legal Name* First Last Phone*Email* What's the name of the 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 Where is your business located?Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code 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 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 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 <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 Owner/Officer Info *Owner NameOwner PayrollOwner Title *Owner NameOwner Date of BirthOwner Gender (assigned at birth)Beneficiary nameBeneficiary relationship 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 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 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 <b>Choose your policy limits</b> <br>(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 Inland Marine InsuranceWhat's your estimated travel radius?* 0-50 miles 50-100 miles 100-250 miles 250-500 miles Over 500 miles Select your desired deductible*The amount you have to pay out of pocket before your insurance company starts helping. $250 $500 $1,000 $2,500 $5,000 High-value item(s) <b>Would you like to cover any equipment or other high-value items on your policy? </b> <br> <i>(These items are typically at least $1000 each.)</i>* 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? Additional Items <b>Would you like to cover any additional items in transit?</b><br><i>(These are typically under $1000 each.)</i>* 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… Business Property Insurance Primary Business Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 coverageThink 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. Business Property Insurance We need some details about the building.Year Built:* What’s the total square footage of the building? How much square footage does your business use?You can measure this, or take a look at your lease. If you work from your home, this would be the square footage of the space used in your home for your business. Number of Floors:How was the building framed?The 'framing' of a wall is the structure that is required for support. Sometimes called 'studs' or '2x4's. Residential buildings are usually constructed with wood framed walls. Block framed exterior walls Metal framed exterior walls Wood framed exterior walls I’m not sure right now Are the exterior walls covered with a masonry veneer?A masonry veneer is a single layer of masonry material that does not provide any structural support. It’s usually decorative materials like brick, cement, stone, or stucco. Answer "yes" if masonry veneer covers more than 2/3 of your building. Yes No Does the building have wood joists/rafters in the roof?Unless the building has a metal roof supported by metal studs, answer ‘yes’. Yes No I'm not sure Do you use any of these safeguards at this location? Sprinkler System Smoke Detectors Burglar Alarms Dead-bolt locks on exterior doors Safes for valuable items None of the above Add Another Location? Yes No Add location Secondary Business Location Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code
