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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


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