New Quote Quote IDautopopulated as uuid Getting Started No contact information will be requested unless you choose to apply after seeing your quotes. Business NameRating StateSelect the primary state where the business operates.Rating State*Select the primary state where the business operates. Select a State...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Ineligible State States currently available for rating are AL, AZ, AR, GA, IN, IA, KS, KY, LA, MS, MO, NJ, NM, NC, OK, PA, SC, TN, & VA. More states coming soon. Are you an agent or the policyholder?AgentPolicyholderAgents are welcome- and compensated. However, you do need to be registered with us. Go ahead and complete your quote- and at the end, we'll collect some agency info from you so we can get you in the system. Section BreakClasses and Rates Class Code Payroll Actions Edit Delete There are no Classes. Add Class Maximum number of classes reached. Ghost Policy? Confirm You Only Need a Ghost Policy Ghost policies are no problem, but you still need to pick a primary operation (above). Just put the payroll as "0" if you have no employees or uninsured subs and check the box to confirm you need a ghost policy.Subtotal- Hidden Price: $0.00 Low LCMAvg LCMHigh LCMAssigned RiskExperience Mod*Please enter a number from .5 to 3.0.ARAP1.0 is Default. If you're unsure, do not change it.Please enter a number from .6 to 2.0.LowDown PymtSubject to carrier billing optionsAverageDown PymtSubject to carrier billing optionsHighDown PymtSubject to carrier billing options Premium Estimate Annual Premium Down Payment Low Average High These are estimates only and not fully underwritten premiums. Let's get you the lowest possible rate! Click 'Continue' to give a little more detail and confirm your rate. Child Entry ID 1Child Entry ID 2Child Entry ID 3Class 1 Description (For Admin View)Class 2 Description (For Admin View)Class 3 Description (For Admin View)Class Code 1 (Admin)Class Code 2 (Admin)Class Code 3 (Admin)Class 1 PayrollClass 2 PayrollClass 3 PayrollBusiness Name*The full legal name of the business.Doing Business As (DBA)Entity TypeSelect...Individual with no LLC or Corporation setup (not required)Legal PartnershipCorporation with 1 owner/officerLLC with 1 owner/officer/memberCorporation with multiple owners/officersLLC with multiple owners/membersChoose the type of business you haveGhost Premium LowGhost Premium AvgGhost Premium High Industry TypeSelect One– Fill Out Other Fields –Primary Owner* First Last Email* Phone* Agency Relationship PreferenceCheck all that apply. Price is my first and only consideration. I want someone who will just write this policy and that's it. If rates are similar, I'd prefer a local agent I'm ok with all payments and questions handled online only 24/7. I definitely want someone by phone if I need something I'm open to having one agent for everything if it saves money. I need to bind immediately. I have a few days. My renewal is weeks or months away. You don't have to apply for more policies right now- but indicating all possible policies you have will help us match you with an agent/company that offers the best value for everything.Your willingness to combine other business or personal policies at some point in the future can help you save!What other policies might you be interested in? General Liability Commercial Auto Other Commercial Policies Personal Home Insurance Personal Auto Insurance Other Personal Policies ContractorsTotal Annual Amount Paid to Insured Subcontractors*Only include the total amount for all classes you will pay to subs who DO HAVE their own Workers Comp or a state approved exemption. If they DO NOT have their own insurance or state exemption, they will be added to your payroll at audit.Subcontractor %Subcontractor Labor?Subcontractor Labor?Do you perform or oversee work above 20' off the ground?*NoYes Business HistoryNumber of Years in BusinessSelect...012345 or moreNumber of Years with Prior Coverage012345Describe the Owners Prior Experience*Prior CoverageIs coverage currently lapsed?NoYesClaims in the last 3yrsPaid and Reserve Dollars- NOT # of claimsClaims in the last 5yrsPaid and Reserve Dollars- NOT # of claims Business InfoBusiness Mailing Address Address Line 1 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Physical Address Same as Mailing Address Line 1 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Does the business have a Tax ID Number (FEIN)?*YesNoFEINSSNPrimary OwnerTotal Payroll (Admin)EstimatesMost Likely EligiblePolicy SelectionsEmployers Liability- Each Injury per PersonEmployers Liability- Each DiseaseEmployers Liability- Each Disease per PersonLead StateThis field is for zapier notifications only.Adword/KeywordLead GradePolicy Effective Date* Date Format: MM slash DD slash YYYY This Date must be at least one business day into the future.Policy Expiration Date* Date Format: MM slash DD slash YYYY Match the Effective Date one year into the future. Agent InfoName of Agency*Agent Name* First Last Agent Email* This email is where underwriting correspondence will be sent. Coverage is not bound until separately confirmed in writing by an authorized representative of a licensed agent, broker, or insurer.* I acknowledge the above statement.
