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Workers Compensation Insurance Application

Company Details

Notice: The following states cannot be written through this program: AK, DE, HI, ND, OH, WA, WY.

Locations / Rating Information

Skip if you have no clerical staff
Skip if you have no vehicle drivers for your business
Each accident / Disease policy limit / Disease each employee

Owners, Partners, Officers, Relatives

Nature of Business / Description of Operations

General Information

Missouri applicants do not have to answer this.

For Restaurants and Bars:

Do you use any of the following cooking methods at any location(s):

Additional Information

APPLICABLE IN TENNESSEE AND VERMONT: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS’ COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, FL, HI, MA, NE, OH, OK, OR, TN OR VT) (DC, LA, ME, VA and WA, INSURANCE BENEFITS MAY ALSO BE DENIED)

 

All policies have conditions, limitations and exclusions, please read the policy for exact verbiage.
Claim scenario circumstances vary in nature and similar claims do not guarantee coverage.

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