Workers Compensation Insurance Quote

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

Locations / Rating Information

Owners, Partners, Officers, Relatives

Nature of Business / Description of Operations

General Information

Any prior coverage declined/cancelled/non-renewed (other than for pandemic, risk class of business or carrier no longer writing) in the last three years?

Yes

N/A

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)

Workers Compensation Insurance Application

Company Details