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1. Select Practice 0%
2. Claims 0%
3. Excluded Officers 0%
4. Included Officers 0%
5. Workforce 0%
6. Outside Sales 0%
7. Hiring Practice 0%
8. Safety 0%
9. Form Uploads 0%
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Workers Compensation

Select the Practice for this Quote Request

To request a quote, create your first practice.
  1. Go to Your Account
  2. Select "Create Your First Practice"

Claims

Are you aware of any incident that may result in a claim? *
Please explain *
Do you have any additional files you'd like to upload?

If you have any case files or other documentation related to this claim, please upload them below.

Drop files here or

Excluded Officers

Please enter the names of any excluded officers and their equity and payroll information.
Leave this section blank if it does not apply.

Excluded officer #1
+ Add New Officer

Included Officers

Please enter the names of any included officers and their equity and payroll information.
Leave this section blank if it does not apply.

Included officer #1
+ Add New Officer

Workforce

Number of full-time employees *
Annual payroll for full-time employees *
Number of part-time employees *
Annual payroll for part-time employees *
Number of independent contractors *
Do your independent contractors have their own insurance *
Annual Payroll for Independent Contractors *
Number of Physicians on Staff *
Number of Nurse/Medical Support on Staff *
Number of Admin/Clerical on Staff *

Outside Sales

Do you have any employees who perform outside sales duties? *
How many outside sales employees do you have? *
Total outside sales payroll *

Hiring Practice

Do you have an application for new hires? *
Do you conduct reference checks for new hires? *
Do you conduct pre-employment physicals? *
Do you conduct drug screenings? *
Do you check their motor vehicle records (MRV’s)? *

Safety

Do you have a formal safety program? *
Do you hold safety meetings? *
Do you provide PPE to your staff? *
Do you have an accident investigation program in place? *
Are there any programs in place (Sharp, Bloodborne, Pathogen, etc?) *

Form Uploads

Are you a new company? *
Please upload a copy of your most recent workers compensation policy *
Drop files here or
Please upload a copy of your value dated (generated within the past 45 days) loss runs for the past 4 years *
Drop files here or

You can acquire these from your current broker or carrier. If you have been in business for less than four years please attach as many years as possible.

What are your expiring premiums? *
What are your renewal premiums? *
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Your Workers Compensation Quote Request has been submitted.

We'll review your quote and will contact you shortly with policy information. To view your quote in progress, please go to your Account Dashboard.

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