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

Provide the Federal Tax ID# of the business.

Required

Provide the State Tax ID# of the business.

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?

Optional

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

Optional

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

Optional

Submission Validation

Required

Enter the Validation Code from above.

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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Location

Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755