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How many total people will need to be covered?

(Use numbers only -- e.g., 10, not ten.)

What is the breakdown of these individuals?

Owners and partners

Full-time employees

Part-time employees

Sub-contractors & consultants

Briefly describe the job functions of the employees that you wish to cover.

Is this coverage needed for a one-time or seasonal event?

Yes
No

How many years has your company been in business?

Less than 1 year
1 year
2 years

3 years
4 years
5+ years

How many years of experience does your senior executive have in your specific industry?

Less than 1 year
1 year
2 years

3 years
4 years
5+ years

Do you currently have Workers' Compensation insurance?

No
Yes

If you currently have Workers' Compensation, please indicate the following:

Current provider

Expiration date

Have you had workers' comp claims filed against your company within the last 3 years?

Yes
No

If there have been claims filed, what was their approximate total value?

When would you like your plan to take effect?

ASAP
Within one month
In one to two months
More than two months
When my current policy expires

Please list your most recent calendar year gross payroll:

Under $100,000
$100,000 - 249,999
$250,000 - 499,999

$500,000-999,999
$1,000,000+

What is your business entity (legal entity)?

Corporation
S Corporation
Limited Liability
Company
Limited Liability
Partnership

Partnership
Sole Proprietorship
Limited Partnership
Professional
Corporation
Nonprofit Corporation

What industry is your company in?

Please describe your business in detail. (e.g. products or services provided, customers served, etc.)

What is the five digit ZIP code for your office location?

What is your e-mail address?

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