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Workers Compensation Policy

Protect your employees and your business.

When do you want your policy to start?

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This policy will go into force on the start date and stay in force for 12 months.

Payments for this policy will stay in effect until cancelled.

About You

Business information

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Business name - Only letters (A-Z), numbers (0-9), & (ampersand), and - (hyphen) are allowed.
Please provide your full name under mailing address.
A business you own and operate, not a business that employs you.
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Incorrect number format
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Invalid phone
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Physical Address

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Name can be between 2 and 70 characters long and can contain letters, hyphens, commas, dots, apostrophes and spaces
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Name can be between 2 and 70 characters long and can contain letters, hyphens, commas, dots, apostrophes and spaces
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WE CANNOT ACCEPT A PO BOX AS A PHYSICAL ADDRESS. KINDLY ENTER A PHYSICAL ADDRESS FOR YOUR BUSINESS.
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Please click here to be directed to an application that is specifically for those whose business is in .

Quote only for this state.

Due to the current natural disaster in your area, we are unable to provide all Inland Marine options associated with this program at this time. All Inland Marine options will be available soon.

Note: If you are trying to add a policy from your customer dashboard and your current policy is expired, please change your State selection above, and then change it back to your correct state. This will allow you to continue to step two. We apologize for any inconvenience this has caused. (i.e., North Carolina > Texas > North Carolina)

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Invalid physical ZIP code

Mailing address

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WE CANNOT ACCEPT A PO BOX AS A PHYSICAL ADDRESS. KINDLY ENTER A PHYSICAL ADDRESS FOR YOUR BUSINESS.
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This field is required
Please click here to be directed to an application that is specifically for those whose business is in .

Quote only for this state.

Due to the current natural disaster in your area, we are unable to provide all Inland Marine options associated with this program at this time. All Inland Marine options will be available soon.

Note: If you are trying to add a policy from your customer dashboard and your current policy is expired, please change your State selection above, and then change it back to your correct state. This will allow you to continue to step two. We apologize for any inconvenience this has caused. (i.e., North Carolina > Texas > North Carolina)

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Invalid ZIP code

Owner Information

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Owner payroll amount will be adjusted subject to state minimum/maximums where applicable.

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Based on your selection, a state-specific owner inclusion/exclusion form will be completed for you regarding your response. To see this from, check you dashboard after purchasing.

General Eligibility

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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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Delivery radius can't exceed 10 miles radius
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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Your application will be submitted for review.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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  Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting.
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Insurance Information

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Claims History

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It usually takes 10-15 seconds to calculate the price after clicking continue. We appreciate your understanding!

Limits of Insurance

Each Employee $1,000,000  
Disease Aggregate $1,000,000  
Disease Each Employee  $1,000,000  
     
     
     

 

Initial payment: {[{ firstPayment|currency }]}
{[{ monthlyPayment.firstPaymentType }]}

We'll automatically charge your card {[{ monthlyPaymentAmount|currency }]}/mo for the next {[{ checkoutData.configuration.monthlyPaymentCount }]} months.

Switch to annual
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Credit card information

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Invalid credit card number
Please enter your credit card and bank information. Your credit card will be used for the down payment and your bank information will be used for the Capital Premium finance agreement monthly draft. If you have questions about alternative payment methods for the capital monthly draft please contact Capital Premium.
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Invalid cvv
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Invalid ZIP code

This feature will create a customer payment profile for your billing information to allow easy checkout during future policy coverage extensions or updates. Credit card information is not stored within our system. All billing information is processed through authorize.net

EZ-Renew

With this beneficial feature your insurance coverage will be continuous without you worrying about having a lapse in your insurance policy.

You will receive a Conditional Renewal Notice prior to the renewal date of your policy. If you wish to cancel your policy, you must notify us in writing prior to the policy renewal date. You can cancel EZ-Renew at any time from your dashboard. Your policy will be renewed with the same coverage's, additional insureds and endorsements as your current policy. If you wish to change any coverages, you can login to your on-line account and make changes to your policy at any time.

Please note that we do NOT store credit/debit card numbers, nor do we share customer details with any third parties. Recurring billing is managed via Authorize.net.

Policy Holder Edit

, ,
Email:
Email:
Mobile number:

Mailing Address is the Same as the Physical Address
Mailing Address:
, ,

Payment Information Edit

Payment Method:

Workers Compensation

Monthly Payment Breakdown

Policy start date: - Policy end date: Edit

If changes are needed, please reach out to your agent.
Edit

Limits of Insurance

Each Employee $1,000,000  
Disease Aggregate $1,000,000  
Disease Each Employee  $1,000,000  
     
     
     

 

Policy Holder Business Information

Edit
Business Type
name
DBA
Mobile number
Website
Business Activities
Business Activities Description
Product Description

Owner Information

Edit
Owner's Full Name
Owner's Title
Are There Any Additional Owners?
Add. Owner's Full Name
Add. Owner's Title
Add. Owner's Full Name (2)
Add. Owner's Title (2)
Add. Owner's Full Name (3)
Add. Owner's Title (3)
Total Annual Owner's Payroll



Owner payroll amount will be adjusted subject to state minimum/maximums where applicable.

Do You Want to Include the Owner(s) in This Coverage?
Based on your selection, a state-specific owner inclusion/exclusion form will be completed for you regarding your response. To see this from, check you dashboard after purchasing.

General Eligibility

Edit
Which of These Business Activities Best Describes You?
Total Number of Employees
Total Number of Part-Time Employees
Total Number of Full-Time Employees
Total Annual Employee Payroll
Do You Have Any Seasonal Employees?
How Many Years Have You Been in Business?
What Is Your Employee Turnover Rate Each Year?
How Often Does the Business Clean Employee Work Areas?
Does the Business Have a Formal Written Safety Program?
Does the Business Offer Group Employee Health Insurance?
What % of Your Gross Sales Are from Alcohol?
Does the Business Deliver to Customers (Not Outsourced e.g. Uber Eats, DoorDash)?
What % of Your Gross Receipts Are From Food Delivery?
How Are the Delivery Employees Paid?
Do Delivery Employees Use a Motorcycle, Scooter or Bicycle?
Are all drivers are between the ages of 25 and 70 years old?
Does the Business Have a Safe Driver Eligibility Criteria Including Driver Eligibility Reviews?
What is the Business's Delivery Radius (in Miles)?
Delivery radius can't exceed 10 miles radius
Does the Business Provide Delivery Time Guarantees?
Does the Business Delivery of Alcohol?
Does the Business Operate a Food Truck?
How Many Stops Does the Food Truck Make in One day?
Do Employees Perform Duties Other Than Food Service (e.g. Event Set Up)?
Does the Business Operate Mobile Catering Services?
Does the Business Operate a Mobile Vending Cart?
Years of Experience in this Trade or Business?
Is the Business Open Between 11pm - 4:30am?
Does the Business Offer a Formal Orientation or Training Program?
Do You Sponsor Any Athletic Teams?
Do Any Employees Perform Work for Other Businesses or Subsidiaries?
Does the Applicant Own, Operate, or Lease Aircraft/Watercraft?
Are There Any Other Entities That You Own or Manage That Still Owe Undisputed Work Comp Premium to Anyone?
Any Tax Liens or Bankruptcy Within the Last Five (5) Years?
Any Work Performed on Barges?
Do You Lease Employees to or From Other Employers?
Is the Applicant Engaged in Any Other Type of Business?
Is There Any Volunteer or Donated Labor?
What Percentage of the Work Is Subcontracted?
If Employees Are Taken Out to Assist with Catering, What Is the Maximum Number of Employees That Would Travel in Any One Vehicle?

Insurance Information

Edit
Who Is Your Current Insurance Carrier?
Any Work Subcontracted to Others Without Certificates of Insurance?
How Long Have You Had Workers Comp Coverage?
Any Prior Coverage Declined, Canceled, or Non-Renewed in the Last Three (3) Years?
Prior Insurance

Claims History

Edit
How Many Losses Have You Had in the Past 4 Years?
If You Have Had a Loss in the Past 4 Years, Was Any Single Loss More Than $50,000?

Additional Insureds

Edit
Unlimited Additional Insureds
Additional Insureds
{[{ ai.name }]}

Employees

Edit
{[{ employee.firstName }]} {[{ employee.lastName }]} + {[{ optionalCoverage.employeePrice|currency }]}

Independent Contractors

Edit
{[{ contractor.firstName }]} {[{ contractor.lastName }]} + {[{ optionalCoverage.independentContractorPrice|currency }]}

Your policy will be issued and your documents available immediately after clicking the "Purchase Policy" button below. Your policy application may be subject to review by our underwriting team to verify that the business operation, product, and/or service meet the eligibility guidelines established for the program. In the event we need further clarification to determine eligibility, we will contact you via email at the email address used to establish your account. If an account is found to be ineligible during the underwriting period, the policy will be subject to immediate cancellation and a full refund will be issued. After the underwriting period, the premium is 100% earned and no refunds will be given.

Your agent will be contacting you soon. There is a pending document to be submitted.
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Due to some information provided, only submit for quote is available.
Please click here to be directed to an application that is specifically for those whose business is in .

Quote only for this state.

You have selected a monthly payment plan. This is how much you will pay per month.
You have selected an annual payment plan. This is how much you will pay annually.
Workers Compensation

Policy Endorsements

Additional insureds

Coverage for Employees

Coverage for Independent Contractors

Loading... $
monthly
annually
$
monthly
DUE TODAY: (downpayment)

Initial payment: {[{ firstPayment|currency }]}
{[{ monthlyPayment.firstPaymentType }]}

We'll automatically charge your card {[{ monthlyPaymentAmount|currency }]}/mo for the next 9 months.

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