Company Details
Notice: The following states cannot be written through this program: AK, DE, HI, ND, OH, WA, WY.
Applicant/Insured Name:
DBA (doing business as, if any):
Contact Name:
Number of Years in Business:
Contact Phone:
Contact Email:
Website:
Mailing Address:
City:
State: - select - Alabama Arizona Arkansas California Colorado Connecticut District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia West Virginia Wisconsin
Zip:
Legal Status: - select - Sole Proprietor Corporation LLC Trust Partnership Subchapter "S" Corp Joint Venture Other
Other Legal Status
Proposed Effective Date:
Federal Employer ID Number:
Does the applicant have a policy with FLIP/Veracity currently? - select - Yes No
Locations / Rating Information
Owners, Partners, Officers, Relatives
Nature of Business / Description of Operations
Please Describe:
General Information
Please explain:
Please explain:
What percentage?
For Restaurants and Bars:
Please explain:
Please explain:
Please explain:
Additional Information
APPLICABLE IN TENNESSEE AND VERMONT: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS’ COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, FL, HI, MA, NE, OH, OK, OR, TN OR VT) (DC, LA, ME, VA and WA, INSURANCE BENEFITS MAY ALSO BE DENIED)
Date:
Signature:
How did you hear about us: - select - Google Facebook Yahoo Referral Other
