Workers Compensation Application

Law Firm Workers' Compensation Quote Request

Short application for Workers' Compensation Insurance

Named Insured(Required)

The legal name of your firm.

Entity Type(Required)

legal entity type

Name(Required)

First Last

Email(Required)

DBA

Your DBA, if any.

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

FEIN(Required)

Employer ID number

Total 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 Number of Owners(Required)

Do owners wish to be covered by workers compensation?(Required)

Depending on the entity type owners may be included but can elect to be excluded.

Total Full Time employees(Required)

Not including owners.

Total part-time employees(Required)

No including owners.

Do you lease employees from others?(Required)

Leased employees typically are part of a PEO arrangement.

Do you use independent contractors?(Required)

Includes any contractor or person you pay via 1099 .

Total number of independent contractors(Required)

Do you currently have workers compensation coverage?(Required)

Yes

Please upload a copy of your policy, if available.

Drop files here or

Max. file size: 98 MB, Max. files: 3.

If not, no worries!

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 disease

Have you had any work comp claims in the past 4 years?

Yes