Workers Compensation Online Application

Name

Name of Company

Street Address

City

County

State

Zip Code

Email Address

Phone Number

Current Workers Comp Insurance Carrier, if none, type NONE

How many years have you been with this carrier

Current Workers Comp policy #

Current Workers Comp policy expiration date

Current Workers Comp Insurance Premium:

Current MOD Factor

Current Workers Comp Insurance Limit & Deductible and States Admitted In

Have you filed any claim with your current Workers Comp carrier?


Please Select Yes No

If you have filed any claims with your current WC carrier, please advise how many and amounts paid, per policy year.

# of full-time employees

# of part-time employees

Owner’s Name

Federal Tax ID#

Years in business

Annual Gross sales

Square Footage

Estimated Payroll per month

Type of Business


Please Select Wholesaler Retailer Manufacturer Contractor Service Other

Please describe your business:

Owners / Partners / Officers : please provide full name, title, date of birth, % ownership, duties and annual remuneration for each.

Payroll Information: Please provide class code, job duties, annual payroll for each.

Does the company own, operate or lease aircraft/watercraft?


Please Select Yes No

Any past, present or discontinued operations involving the storing, treating, discharging, applying, disposing, or transporting of hazardous material?


Please Select Yes No

Any work performed underground or above 15 feet?


Please Select Yes No

Any work performed on barges, vessels, docks, bridge over water?


Please Select Yes No

Is applicant involved in any other type of business?


Please Select Yes No

Are sub-contractors used? If yes, please give % of work subcontracted in additional comments at the end of this form


Please Select Yes No

Any work sublet without certificates of insurance?


Please Select Yes No

Is a written safety program in operation?


Please Select Yes No

Any group transportation provided?


Please Select Yes No

Any employees under the age of 16 or over the age of 60?


Please Select Yes No

Any seasonal employees?


Please Select Yes No

Is there any volunteer or donated labor?


Please Select Yes No

Any employees with physical handicaps?


Please Select Yes No

Do employees travel out of state?


Please Select Yes No

Are athletic teams sponsored?


Please Select Yes No

Are physicals required after offers of employment are made?


Please Select Yes No

Any prior coverage declined/cancelled or non-renewed in the last 3 years?


Please Select Yes No

Is there a labor interchange with any other business or subsidiary?


Please Select Yes No

Do you lease employees to or from other employers?


Please Select Yes No

Do any employees predominately work at home?


Please Select Yes No

Any tax liens or bankruptcy within the last 5 years?


Please Select Yes No

Any undisputed and unpaid workers comp premium due from or any commonly managed or owned enterprises? If yes, please explain below.


Please Select Yes No

Additional Comments

Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@zolofrainsurance.com. Do not “Refresh” the page because all data entered onto the form will be lost.