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Workers Compensation Insurance Application
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Owner Name
*
First
Last
Phone
*
Email
*
Website
Preferred Method of Contact
Call
Text
Email
Business Details
Legal Business Name
*
FEIN
Business Address
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Status
Sole Proprietor
Limited Liability Co
Corporation
S Corp
Partnership
Non-Profit
Trust
Religious Organization
Employer's Liability Insurance
*
--- Select Choice ---
$100,000/$500,000/$100,000
$500,000/$500,000/$500,000
$1,000,000/$1,000,000/$1,000,000 Choice
Proposed Effective Date
Date
Time
Type of Business/Industry
Artisan Contractor
Retail Services
Manufacturing
Transportation
Restaurant
Sales
Healthcare
Other
If other, please explain
Year Business Began
Date
Time
Payroll Information
Total Number of Full Time Employees
*
(full time/part time)
Total Number of Part Time Employees
*
Estimated Annual Payroll
*
Coverage Details
Include or exclude owner?
Include
Exclude
Do subcontractors carry their own workers comp?
*
Yes
No
Any subcontractors used?
*
Yes
No
Annual amount paid to subcontractors?
Claims History
Do you currently have workers compensation insurance?
*
Yes
No
If so, please provide carrier name.
Date workers coverage.
If not, please provide reason for lapse in coverage. (N/A for startups)
Date current policy expires.
Date
Time
Any workers comp claims in the past 5 years?
*
Yes
No
File Upload
Drag & Drop Files,
Choose Files to Upload
Upload current insurance declarations.
Consent
I agree to be contacted by Merrill Insurance Agency, Inc. regarding my quote request.
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