Workers Compensation ApplicationStep 1 of 520%Entry Date Date Format: MM slash DD slash YYYY IndustryClassControllling AgentName*Email* Briefly describe your business operations.*Business NamePhone*Location Address* Street Address City State / Province / Region ZIP / Postal Code Annual Gross Sales (Estimated)*Gross sales are the total amounts (before expenses) that a company earns and records from the sales of its products or services.Entity Type*- Select -IndividualPartnershipCorporationLLCOtherYear Business Started*Is this a home based business?*YesNoDo you have any employees?*YesNoNumber of Employees*12-56-1011-2526-100100+Annual Employee Payroll (Estimated)*Do not include payroll for owners, officers or partners.Do you hire subcontractors?*YesNoIn addition to Workers Compensation, please indicate any other quotes to include. General Liability Professional Liability Commercial Auto PropertyQuestions?Call 800-858-1315 Mon-Fri, 7am-5pm Pacific Time