Workers’ Compensation Insurance Application
Business Information
Business Name
Type of Business
Business Address
City
State
ZIP Code
Business Phone
Email
Owner Information
Owner's Name
Owner's Phone
Owner's Email
Policy Details
Number of Employees
Estimated Annual Payroll
Desired Policy Start Date
Business Operations
Describe Business Operations
Previous Workers’ Compensation Insurance?
Yes
No
Any Claims in Past 5 Years?
Yes
No
Additional Information
Notes