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Workers Comp Quote
Workers Comp Insurance Quote Form
Workers Comp Quote
Rhett Jessop
2021-11-01T17:42:06-06:00
Step
1
of
4
25%
Do you currently have Worker's Comp?
(Required)
Yes
No
Policy Effective Date
(Required)
When would you like this policy to be effective?
MM slash DD slash YYYY
State
(Required)
Alaska
Arizona
Arkansas
California
Colorado
Delaware
Florida
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maryland
Michigan
Minnesota
Mississippi
Missouri
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
Oklahoma
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Zip Code
(Required)
Company Name
(Required)
DBA Name
If applicable
Entity Type
(Required)
Limited Liability Company
Partnership
Corporation
Sole Proprietor
Other
EIN
(Required)
Owner's Name
First
Last
Phone
Email
DOT Number
Current Cost of Worker's Comp Policy?
This field is hidden when viewing the form
Multiple Locations: No
Do you want to include owners?
(Required)
Owners can be excluded. If you include owners, it will cost more.
Yes
No
This field is hidden when viewing the form
Class Code: 7219
Full Time Employees
(Required)
W-2 Employees only
Part Time Employees
(Required)
W-2 Employees only
Total Annual Payroll
(Required)
Your company's total payroll for W-2 Employees. Do not include owners' payroll unless you wish to include them in the coverage.
This field is hidden when viewing the form
Experience Modification: Skip
How many years has the business continuously had workers' comp insurance?
(Required)
Less than a year
1 year
2 years
3 years
More than 3 years
Has the business ever had worker's comp insurance?
(Required)
Yes
No
How long has the business had at least one employee, excluding owners and officers?
(Required)
The business hasn't hired employees
Less than a year
1 Year
2 Years
3 Years
More than 3 years
Has the business had any claims or work-related injuries in the last 3 policy periods?
(Required)
Yes
No
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Does the insured have any employees that drive more than 10% of the time?: Check
This field is hidden when viewing the form
Are MVRs for all drivers reviewed by the insured or the insured's commercial auto insurer?: Yes
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Does the insured have a vehicle inspection and maintenance program in place?: Yes
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Do 4 or more employees ever travel in a vehicle at the same time?: No
Does your business haul any explosives, combustibles (other than gasoline), highly corrosive materials, live animals, or logs?
(Required)
Yes
No
What is your maximum delivery radius (in miles)?: 500 Miles
This field is hidden when viewing the form
What percentage of your total labor expense is owner/operators versus W2 Employees?: 0%
Do drivers manually load and unload product?
(Required)
Yes
No
Does the insured have any known violations or crashes submitted to the FMCSA within the last 3 years?
(Required)
Yes
No
This field is hidden when viewing the form
Employers' Liability Limits: $1m / $1m / $1m
This field is hidden when viewing the form
Description of business operations: General Freight, For Hire Trucking
Comments
This field is for validation purposes and should be left unchanged.
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