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Worker's Compensation


?Please note: Any corporate officer in the construction industry that does not hold a valid exemption with the state of Florida MUST be included for workers compensation coverage - even if that officer does no actual work. Please provide an estimated annual payroll amount for each corporate officer.


Additional Documents that may be requested:

You will be contacted by a member of our Customer Service Team and the may request the additional information below.

? Loss Runs and dec pages for any previous coverages

? Copies of any exemptions for all exempted officers

? Copies of any state and or county licenses

? Copies of your last 4 UCT-6, 941 or letter stating that your business does not file these tax forms

? Current Certificates of Insurance for all subcontractors used. Certificates must have been issued with in the last 30 days



Company Name
Required
Company Owner
Required
Number of Owners
Optional
Street Address
Optional
City, State. ZIP Code
Optional
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Fax #
Required
E-Mail Address
Required
Federal Employer Identification Number
Required
Complete Description of Work Performed
Optional
License (State, Number)
Optional
Percentage of Commercial Work
Optional
Percentage of Residential Work
Optional
Year Company Established
Optional
Years Experience in Industry
Optional
Any Workers Compensation Claims?
Optional
Any lost time claims?
Optional
Prior Insurance
Optional
How long have you had WC coverage?
Optional
Name DOB SSN %Ownership Title Duties Exempt?
Optional
Prior Businesses in past 5 Years?
Optional
List Names, FEIN's, and Officers indicating ownership
Optional
First Name
Required
Last Name
Required
E-Mail Address
Required
ZIP / Postal Code
Required
Job Description and Estimated Payroll
Optional
Estimated Annual Revenue?
Optional
Effective Date Desired?
Optional
Do You have a written safety plan, and if so, please attach
Optional
Do you use subcontractors and what %of your work is subcontracted?
Optional
Do YOu use any uninsured subcontractors or 1099 workers?
Optional
Do you require proof of workers compensation from subcontractors and do you use a diary system to keep track of them?
Optional
Are any subs used with an exemption only?
Optional
Any subs that use a staff leasing company for their employees
Optional
Do you require a notarized statement from subs with exemptions only?
Optional
Does your busines own/operate watercraft or aircraft?
Optional
Does your company handle hazardous material
Optional
Do you work more than 3 feet underground or over 15 feet above ground? If so, please explain.
Optional
Do You work from scaffolds, lifts or ladders? If so, please explain
Optional
Do you provide group transportation, (more than 2)? If so, please explain
Optional
Any employees under 16 or over 60?
Optional
Do employees routinely travel out of state?
Optional
If this is a new business venture, or if you have never had coverage before, please write a brief summary of your career to date, including any supervisory positions you have held, or why you have not had coverage before.
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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