Workers Compensation Online Application

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name(Required)

Last Name(Required)

Number of Owners(Required)

Name(s) of Company Owner(s), with % ownership(Required)

Description of Operations:(Required)

Formal Name of Business(Required)

Business Type(Required)

Street(Required)

City(Required)

State(Required)

ZIP / Postal Code(Required)

Primary Phone Number(Required)

E-Mail Address(Required)

Website Address:(Required)

Provide the person to contact for audit purposes, include name, address number and email address.(Required)

Year Established(Required)

Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?(Required)

Advise if the owner(s) of this company owns another company, if so, provide details on other company and ownership % in other company.(Required)

Do you perform services in the State of New York?(Required)

If “Yes,” what percentage is performed in the five (5) boroughs and what percent in the rest of New York?

Please list all States in which you operate.(Required)

Estimated Annual Gross Revenue(Required)

Prior 12 months annual gross revenue(Required)

Advise if the owners of this company want coverage as well. If yes, advise job duties for each owner and approximate annual payroll for each owner.(Required)

Number of full-time employees(Required)

Number of part-time employees(Required)

Number of temporary/ seasonal employees(Required)

Number of independent contractors(Required)

By category, provide estimated annual payroll paid to: owners, employees, temporary/seasonal and independent contractors.(Required)

Do you use subcontractors?(Required)

When hiring subcontractors, check off all that apply:(Required)

Hold down the Ctrl Key to make multiple selections.

What percentage of your work includes the subcontracting of work to others?(Required)

Annual Cost of Subcontractors(Required)

Are subconsultants and subcontractors hired under a written, standard subcontract?(Required)

Advise if this company has ever had a Workers Compensation policy, provide details.(Required)

Does this company has a current Workers Compensation Insurance policy?.(Required)

Effective Date

Current Policy End Date(Required)

Current Limits(Required)

Current Deductible(Required)

Current Premium(Required)

Does the firm currently have General Liability Insurance in place?(Required)

If yes, please provide name of General Liability insurer and approximate expiration date:(Required)

Advise how disbursements to employees or independent contractors will be tracked. (check register, spreadsheet, etc)(Required)

If you are not tracking these disbursements, advise the name of the company, their address and telephone number. (CPA, payroll co, etc.)(Required)

Advise if this company has ever filed a Workers Compensation claim, provide details.(Required)

Advise if this company has ever had an unpaid or unresolved Workers Compensation audit, provide details.(Required)

Additional Comments

Workers Compensation Online Application

Personal Information

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