Workers' Compensation Quick App | Flagship Insurance

Business Name:
Business Phone:
Business Website (if any):
Business Address:
Street Address Address Line 2 City State ZIP Code
Federal Tax ID:
Effective Date:
Date Format: MM slash DD slash YYYY
Current Premium:
Current Insurer:
Legal Entity
- LLC
- Corp
- Partnership
Nature of Business/Description of Operations:
Emp Liability Limits Desired:
- 100/500/100
- 500/500/500
- 1M/1M/1M
Class Code (or work done). For example – “Carpentry” and $100K in payroll or “Office” and $50,000 in payroll. Or both.
Work Performed/Done: Payroll:
Year Business Started:
Do you have workers’ compensation coverage inforce?
- Yes
- No
Any Claims Past 5 Years?
- Yes
- No
If a claim, please describe:
Hours of Operation: Open after 6:00 PM?
- Yes
- No
Do employees ever work at heights exceeding 15 feet?
- Yes
- No
Are employees involved in trucking or transportation operations?
- Yes
- No
Do employees handle hazardous materials?
- Yes
- No
Number of full-time employees:
Number of part-time employees:
Maximum number of employees working at one time at a location:
Your Name:
First Last
If you have any questions on this application, please contact Bill Cleave at bcleave@flagshipins.com or 609-818-9534.

Work Performed/Done:	Payroll:

Workers’ Compensation Quick App