Workers Comp Request A few questions is all we need to get started on finding you the best Workers Comp program for your business Step 1 of 4 - Business 25% Do you prefer to answer as many questions online as possible or speak with an agent?*I'll answer as much as possible onlineI'd rather speak with an agent Business Name* Type of Organization*LLCCorporationPartnershipSole Prop / IndividualNon-ProfitOtherContact Name* First Last Email* Phone* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Describe your Business Operations*How Many Employees?* How many claims have you had in the last 3 years?*Our underwriters will ask to verify claim history with recent loss runs from your current company.01-56-1010+Employee Classifications*Check any of the following employee classifications that apply to your operation. If you have classifications other than this common list, please add in the comments section before you Submit. Office / Clerical Outside Sales Construction Service & Cleaning Medical Professional Auto Repair Restaurant & Hospitality Transportation & Delivery Farm Labor Mining Aviation Office / ClericalEnter your estimated annual Office / Clerical payroll Outside SalesEnter your estimated annual Outside Sales payroll ConstructionEnter your estimated annual Construction payroll (if you have multiple trades we will separate out further). Medical ProfessionalEnter your estimated annual Medical Professional payroll. Auto RepairEnter your estimated annual Auto Repair payroll. Restaurant & HospitalityEnter your estimated annual Restaurant & Hospitality payroll. Transportation & DeliveryEnter your estimated annual Transportation & Delivery payroll. Service & CleaningEnter your estimated annual Service & Cleaning payroll. FarmEnter your estimated annual Farm payroll. MiningEnter your estimated annual Mining payroll. AviationEnter your estimated annual Aviation payroll. Upload Current DocumentsIf available, please upload your current Workers Comp policy pages.Max. file size: 39 MB.What is your Tax ID / EIN? EIN required for LLCs and Corporations. SSN required for Sole ProprietorsCommentsIs there anything else we should know?CommentsThis field is for validation purposes and should be left unchanged.