🦺 Specialty Quote Form

Workers Compensation Insurance Quote

Complete this form so we can find you the right workers comp coverage. A licensed broker will respond within one business day.

✓ No obligation

✓ Multiple carriers compared

✓ Response within 1 business day

✓ 18+ years commercial experience

📅

Policy Effective Date

When do you need coverage to start?

Requested Effective Date * Reason for This Date * Select one... New business / first policy Current policy expiration Mid-term switch Business acquisition / takeover Other Current Policy Expiration Date (if renewing or switching carriers) 🏢 Business Identity Legal name, DBA, FEIN, and contact details Corporation / Legal Name * DBA (if different) FEIN / EIN # * Legal Entity Type * Select... Sole Proprietorship Partnership LLC S-Corporation C-Corporation Non-Profit Other Owner Contact Owner's Full Name * Owner's Cell Phone * Owner's Email Address * 📍 Business Location Physical address where employees work Why this matters: Workers comp rates are partly determined by the state where your employees work. If you have employees in multiple states, note that in the additional info field at the bottom. Physical Property / Street Address * City * State * Select... WashingtonOregonIdaho NevadaArkansasSouth Dakota PennsylvaniaTexasIndiana Other ZIP Code * Year This Building Was Built * How Many Stories? * Select... 1 story 2 stories 3 stories 4+ stories Building Construction Type *

Reason for This Date

Current Policy Expiration Date (if renewing or switching carriers)

🏢

Business Identity

Legal name, DBA, FEIN, and contact details

Corporation / Legal Name

DBA (if different)

FEIN / EIN #

Legal Entity Type

Owner Contact

Owner's Full Name

Owner's Cell Phone

Owner's Email Address

📍

Business Location

Physical address where employees work

Why this matters: Workers comp rates are partly determined by the state where your employees work. If you have employees in multiple states, note that in the additional info field at the bottom.

Physical Property / Street Address

City

State

ZIP Code

Year This Building Was Built

How Many Stories?

Building Construction Type

Year Business Started at This Location * ⚙️ Business Operations What your business does and when it operates Type of Business / What Your Business Does * Hours of Operation * Total Annual Sales / Receipts * Select range... Under $250,000 $250,000 – $500,000 $500,000 – $1,000,000 $1,000,000 – $2,500,000 $2,500,000 – $5,000,000 $5,000,000 – $10,000,000 Over $10,000,000 👷 Employees & Payroll Headcount, payroll, and workforce details Tip: Workers comp premiums are primarily based on payroll and job classification. Include all employees — owners, part-time workers, and seasonal staff — in your totals. Number of Full-Time Employees * Number of Part-Time Employees * Total Annual Payroll — All Employees * Select range... Under $100,000 $100,000 – $250,000 $250,000 – $500,000 $500,000 – $1,000,000 $1,000,000 – $2,500,000 $2,500,000 – $5,000,000 Over $5,000,000 Maximum Number of Employees at This Location at One Time * Are Any Employees Under 16 Years of Age? *

⚙️

Business Operations

What your business does and when it operates

Type of Business / What Your Business Does

Hours of Operation

Total Annual Sales / Receipts

👷

Employees & Payroll

Headcount, payroll, and workforce details

Tip: Workers comp premiums are primarily based on payroll and job classification. Include all employees — owners, part-time workers, and seasonal staff — in your totals.

Number of Full-Time Employees

Number of Part-Time Employees

Total Annual Payroll — All Employees

Maximum Number of Employees at This Location at One Time

Are Any Employees Under 16 Years of Age?

No Yes

Do You Provide Health Insurance to Employees? *

Yes — all full-time employees Yes — some employees No

📝

Additional Information (Optional)

Anything else that helps us get you an accurate quote

Current Workers Comp Carrier (if applicable) Any Workers Comp Claims in the Last 5 Years? *

Any Workers Comp Claims in the Last 5 Years?

No claims Yes — I'll describe below

Do Employees Work at Multiple Locations or States?

Do You Use Subcontractors? If So, Do They Carry Their Own WC?

Anything Else We Should Know

📎

Upload Documents (Optional)

Attach your current dec pages and/or loss runs to speed up quoting

Why upload? Attaching your current declarations page and loss run history allows us to return a more accurate quote faster — and compare your existing coverage side-by-side with new options. Both documents are optional but helpful.

Current Dec Page(s)

📄

Declarations Page

Your current policy's first page showing coverage limits, carrier, and policy period

PDF JPG PNG DOC

Loss Runs

📊

Loss Run Report

Claims history from your current or prior carrier — typically 3–5 years

PDF XLS JPG DOC

Max 10 MB per file · Files are transmitted securely · You can also email documents directly to CommercialInsuranceAgency@gmail.com

Ready to Submit?

A licensed commercial broker will review your submission and respond within one business day with workers comp options tailored to your business.