New Quote HiddenUnique ID For Jornaya, AWLHiddenQuote ID For rating data Getting Started No contact information will be requested unless you choose to apply after seeing your quotes. Business Name HiddenRating 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. Need a Ghost Policy? I Need a Ghost Policy Ghost policies are real workers comp policies that will satisfy state requirements- but there is no employee payroll, and no uninsured subcontractors. We can do Ghost Policies! Did you know combing a General Liability policy or personal policies with your workers comp can make it cheaper with multi-policy discounts? When you get to the next screen, add a single job description to describe what your business does and in the payroll field, enter "0" (zero). Some of our ghost policies even have payment plans! Are you an agent or the policyholder? Agent Policyholder Agents 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. HiddenSection BreakClasses and RatesEach "Class" is a description of the work your business performs. Click the Add button below to list the type of work your business performs. Class Code Payroll Actions Edit Delete There are no Job Descriptions. Add Job Description Maximum number of job descriptions reached. Subtotal- Hidden Price: $0.00 HiddenLow LCMHiddenAvg LCMHiddenHigh LCMAssigned RiskHiddenExperience Mod*Please enter a number from .5 to 3.0.HiddenARAP1.0 is Default. If you're unsure, do not change it.Please enter a number from .6 to 2.0.HiddenLowHiddenDown PymtSubject to carrier billing optionsHiddenAverageHiddenDown PymtSubject to carrier billing optionsHiddenHighHiddenDown 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. HiddenChild Entry ID 1 HiddenChild Entry ID 2 HiddenChild Entry ID 3 HiddenClass 1 Description (For Admin View) HiddenClass 2 Description (For Admin View) HiddenClass 3 Description (For Admin View) HiddenClass Code 1 (Admin) HiddenClass Code 2 (Admin) HiddenClass Code 3 (Admin) HiddenClass 1 PayrollHiddenClass 2 PayrollHiddenClass 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 haveHiddenGhost Premium Low HiddenGhost Premium Avg HiddenGhost Premium High HiddenIndustry 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 HiddenContractorsTotal 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.HiddenSubcontractor %HiddenSubcontractor Labor? HiddenSubcontractor Labor? Do you perform or oversee work above 20' off the ground?* No Yes Business HistoryNumber of Years in BusinessSelect...012345 or moreNumber of Years with Prior Coverage012345Describe the Owners Prior Experience*HiddenPrior 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)?* Yes No FEIN SSN Primary OwnerHiddenTotal Payroll (Admin)HiddenEstimatesHiddenMost Likely Eligible HiddenPolicy SelectionsHiddenEmployers Liability- Each Injury per Person HiddenEmployers Liability- Each Disease HiddenEmployers Liability- Each Disease per Person HiddenLead State This field is for zapier notifications only.HiddenAdword/Keyword HiddenLead Grade Policy Effective Date* MM slash DD slash YYYY This Date must be at least one business day into the future.HiddenPolicy Expiration Date 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.
