Workers Comp Application

Please complete and submit this form, and a member of our team will be in touch with you soon to discuss the next steps. Thank you!

"*" indicates required fields

Your Name*

Your Email*

Company Name*

Current Carrier*

Preferred Policy Effective Date*

Federal Employers ID Number (FEIN)*

Number of Employees*

Estimated Annual Payroll*

Do you Lease, Operate or own an Aircraft?*

Do the Partners, Shareholders or Sole Proprietor elect to be covered?*

Estimated Payroll of Partners/Shareholders, if NOT included above*

Please provide the following information for Partners/Shareholders desiring coverage:

Name*

Title*

Percentage*

Name

Title

Percentage

Name

Title

Percentage

Name

Title

Percentage

Loss History (if none, please sign and attach No Claims Declaration)*

Download No Claims Declaration (PDF)

File

Max. file size: 50 MB.

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