Workers Compensation Application Step 1 of 5 20% HiddenEntry Date MM slash DD slash YYYY HiddenIndustry HiddenClass HiddenControllling Agent Name* Email* Briefly describe your business operations.* Business Name Phone*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?* Yes No Do you have any employees?* Yes No Number of Employees*12-56-1011-2526-100100+Annual Employee Payroll (Estimated)*Do not include payroll for owners, officers or partners.Do you hire subcontractors?* Yes No In addition to Workers Compensation, please indicate any other quotes to include. General Liability Professional Liability Commercial Auto Property Questions? Call 800-858-1315 Mon-Fri, 7am-5pm Pacific Time
