Law Firm Workers' Compensation Quote Request Short application for Workers' Compensation Insurance Named Insured(Required) The legal name of your firm. Name(Required) First Last Email(Required) DBA Your DBA, if any. Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)FEIN(Required)Employer ID numberTotal Remuneration of employees(Required)Workers compensation is rated based on total remuneration. Which includes: Payroll - wages and salaries; Commissions and draws against commissions; Bonuses Extra pay for overtime as defined and outlined in their rule V-E; Holiday, vacation and sick pay; Total estimated annual wages of all employees including overtime. If in NV please cap payroll at $36k per employee. Total Full Time employees(Required)Total part-time employees(Required)Do you lease employees from others?(Required)NoYesLeased employees typically are part of a PEO arrangement. Do you use independent contractors?(Required)YesNoIncludes any contractor or person you pay via 1099 regardless of whether they have their own workers compensation coverage.Do you currently have workers compensation coverage?(Required) Yes No Current Workers Compensation Insurer Name of your current workers compensation insurance company. Your current or desired employer liability limits Typically: $100,000 per occurrence for bodily injury $100,000 per employee for bodily injury by disease $500,000 aggregate for bodily injury by disease or $500,000 per occurrence for bodily injury $500,000 per employee for bodily injury by disease $500,000 aggregate for bodily injury by disease or $1,000,000 per occurrence for bodily injury $1,000,000 per employee for bodily injury by disease $1,000,000 aggregate for bodily injury by diseaseHave you had any work comp claims in the past 4 years? Yes No
