Workers Compensation

Requesting for
Business Owner’s InsuranceWorkmen’s Comp InsuranceBoth

Contact Information

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Once received, one of our Representatives will contact you within 24-48 hours. We appreciate the opportunity to serve you.

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Business Owners General Information
Purpose of Application

Desired Effective Date

Year Business was established or acquired from previous owner
Type of Business Entity
Individual

Corp
Other
Legal Business Name

If Other. D/B/A Name

Federal Tax ID

Business Owners Building Information
Year Building Built

Owner or Tenant?
OwnerTennant

Building Coverage Limit (Building Owners Only)

Sq. Footage of Building*

Sq. Footage of Office*
Sq. Footage of Office*

Personal Property Coverage*
(Amount needed to replace contents)

Personal Property Deductible Option
$500 (Most Common)$1000
General Liability Limit
1,000,000/2,000,000Other

Full Time Employees

Part Time Employees

Type of Outside Construction
BrickStuccoOther

Building Sprinklered
Yes

No
Fire Alarm
NoneLocalCentral
Buglar Alarm Type
NoneLocalCentral
Number of Stories

Basement
YesNo
Year Updates Were Completed (if building over 25 years old)

Additional Interest: If you need anyone listed as an additional insured or Loss Payee, please list below.

Reason

Name of Interest

Street Address

City

State, Zip

Worker’s Compensation Information
Full time Employees

Part time Employees

Umbrella Coverage

Umbrella Coverage? YesNo
Limit 1m2m

Include Doctor YesNo

Annual payroll of Doctor

Payroll Amount for Massage Therapists

Annual Expected Payroll

Claims History YesNo

If Yes, Please Specify...

Has Prior Coverage ever been cancelled? YesNo

If Yes, Please Specify...

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