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Workers’ Compensation Quick App
Business Name:
Business Phone:
Business Website (if any):
Business Address:
Street Address
Address Line 2
City
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California
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Delaware
District of Columbia
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Tennessee
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.