Workers Compensation Quote Application Form - 1 Reason Insurance (715)598-9924

Workers compensation is required in most states for most employers. If you have employees or are about to hire your first employee, you should make sure you know what your responsibilities are for covering your staff.

Many contractors find they’re required to have workers’ compensation insurance to satisfy contractual requirements, and elect to have a workers’ comp policy that doesn’t actually cover any workers and/or employees. We call these policies “Workers’ Comp Ghost Policies,” albeit so-called “ghost policies” are one in the same as any other policy regarding coverage with the one exception of no employees are listed at the inception of the policy. We write a lot of workers’ comp policies, both with employees and without. If you want to know more specifically about “ghost policies” you can learn more about them by CLICKING HERE, or simply filling out the form below and receiving a quote and discussion regarding coverage.


                

        
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                                    Legal name operating under ( Examples "My Business LLC", or "Mary Smith dba My Business")*
                            
                            
                                                    
                                                    Legal Business Name:
                                                
                            
                            
                            
                        
Contact name
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Company email address*
                            
                        
Business entity*
Company phone*
Cellphone number
Address*    
                    
                         
                                        Street Address
                                        
                                    
                                        Address Line 2
                                        
                                    
                                    City
                                    
                                 
                                        State
                                        
                                      
                                    ZIP Code
                                    
                                
                    
                
Date Business Started*
                                            
                                            MM
                                        

                                            
                                            DD
                                        

                                            
                                            YYYY
                                       
                                   
Federal employer Identification number (FEIN/EIN)*
                    
                    
                          
                    
                
                
                    
                        Description of business*
Number of owners and officers*
#1 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 Months  
      
#1 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 Months)  
      
#2 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 Months)  
      
#1 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 months)  
      
#2 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 months)  
      
#3 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 months)  
      
#1 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 Months)  
      
#2 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 Months)  
      
#3 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 Months)  
      
#4 Owner/Officer name*Title First Name Last Name Respected Duties Percentage of Ownership Payroll (in next 12 Months)  
      
Do you want to exclude any officers and/or owners from coverage?*
Do you have employees?*
Number of full-Time employees (if any)*Please enter a number from 0 to 10000.
Number  of part-time employees (if any)*Please enter a number from 0 to 10000.
Expected total payroll (Not Including officers/owners) in the next 12 months"*
Has there been previous workers' compensation coverage?*
Is there any unpaid workers' compensation premium due?*
Are there any workers' comp audits not completed?*
Previous workers' compensation policies with outstanding audits are highly likely to prevent the same entity (and owners) from receiving a new workers' comp policy
                    
                    
                          
                    
                
                
                    
                        Own, operate, or lease aircraft or watercraft for business?*
Please provide details
Manufacture, transport, or handle hazardous materials?*
Please provide details.
Perform work more than one story below ground or above two stories?*
Please provide details.
Engage in any other type of business?*
Please provide details.
Subcontractors without obtaining certificates of insurance and/or certificates of exemption?*
Please provide details.
Have any employees under 16 years of age?*
Please provide details.
Have a lay-off period of longer than 3 months?*
Please provide details.
Use volunteer or donated labor?*
Please provide details.
                    
                    
                          
                    
                
                
                    
                        Have a cancellation, non-renewal, or lapse in coverage in the last year?*
Please provide details.
Interchange employees with any other entity/subsidiary?*
Please provide details.
Lease employees to or from other employers?*
Please provide details.
Have a majority of home-based employees?*
Please provide details.
Do you employ drivers?*
Please provide details.
Have any tax liens or bankruptcy in the last 5 years?*
Please provide details.
Have greater than 50 percent ownership of any other businesses?*
Please provide details.
Any worker compensation claims or losses within the last three years*
Please provide details.