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Workers’ Compensation Quote
Workers’ Compensation Quote
Nicholas Slahta
2024-03-01T08:00:18-05:00
Step
1
of
4
25%
Do you currently have Worker's Comp?
(Required)
Yes
No
What is the name of the insurance company who writes your current Worker's Comp policy?
(Required)
Current Cost of Worker's Comp Policy?
Desired Policy Effective Date
(Required)
MM slash DD slash YYYY
Owner's Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Company Name
(Required)
DBA Name
If applicable
Entity Type
(Required)
Limited Liability Company
Partnership
Corporation
Solo Proprietor
Other
DOT Number
(Required)
Company Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
EIN
(Required)
Year business was established?
(Required)
Do you want to include owners?
(Required)
Yes
No
Owners can be excluded. If you include owners, it will cost more.
# of Full Time Employees
(Required)
W-2 Employees only
# of Part Time Employees
(Required)
W-2 Employees only
Estimated Gross Revenue
(Required)
This can be a conservative estimate.
Owner(s) Annual Payroll
(Required)
Your company's total payroll for all owners. It's best to be conservative to start. We can increase payroll if needed during policy period.
Employee Annual Payroll
(Required)
Your company's total payroll for W-2 Employees only, NOT including any owners. It's best to be conservative to start. We can increase payroll if needed during policy period.
Contractor Annual Payroll
Enter $0 if you do not hire subcontractors
What is the furthest any of your vehicles travel in any one direction from their home base?
(Required)
0 - 50 miles
51 - 100 miles
101 - 200 miles
201 - 500 miles
501+ miles
Are there any drivers that drive trucks you own or lease but pay via 1099?
(Required)
Yes
No
In the past 3 years how many Workers' Compensation claims were reported?
(Required)
None
1
2
3
4
5
6 or more
Do any owner operators or sub-haulers transport goods on your behalf?
Yes
No
Do you review MVRs for all employees with a driving exposure?
(Required)
Yes at the time of hire and annyally
Yes at the time of hire only
No
N/A - I am an independent contractor
Do you currently have a Workers' Compensation insurance policy in effect?
(Required)
Yes
No
When was your last policy in effect?
(Required)
Never no prior insurance
Within the last 30 days
30 days to 6 months ago
More than 6 months ago
In the past 3 years how many Workers' Compensation claims were reported?
(Required)
None
1
2
3
4
Do you transport any hazardous materials?
(Required)
Yes
No
Do you do manual tarping?
(Required)
Yes
No
Do your drivers do any manual loading/unloading of materials?
(Required)
Yes
No
Do drivers use chains to secure equipment, logs, or other large loads for transport?
(Required)
Yes
No
Do the business owner(s) of this business have a combined majority ownership in any other transportation business?
(Required)
Yes
No
Do you have multiple locations in more than one state?
(Required)
Yes
No
This field is hidden when viewing the form
Employers' Liability Limits: $1m / $1m / $1m
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