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EZ Workers' Comp

Workers' Compensation Made Easy

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Workers Comp Programs
Insurance Regulations by States

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Home
Workers Comp Programs
Insurance Regulations by States

Request a Quote

Business Information

Legal Business Name

Address

Type of Business

State

City

Zip Code

Federal Tax ID Number

Website

Contact Person

Email

Phone

Agent/Referral Name

Agent/Referral Phone

Agent/Referral Email

Description of Operations

Owner

Name

Title

Ownership %

Included or excluded?

Owner 2

Name

Title

Ownership %

Included or excluded from coverage?

Owner 3

Name

Title

Ownership %

Included or excluded from coverage?

Insurance Information

Date Business Established

Do you have an active Workers Compensation policy in place?

If yes, list Carrier Name

Effective date of policy

Have you had any losses in the last 3 years?

Upload the Acord and Loss Runs

Do you currently offer Voluntary Benefits?

If yes, list Carrier Name

Effective Date

Job Descriptions and Class Codes

Job Description or Class Code

Full time employees

Part-time employees

Estimated Annual Payroll

Job Description or Class Code

Full time employees

Part-time employees

Estimated Annual Payroll

Job Description or Class Code

Full time employees

Part-time employees

Estimated Annual Payroll

Selection

01 ) Has your workers’ compensation been non-renewed in the past 3 years?

Yes No

02 ) Do you currently have coverage in force?

Yes No

03 ) Do you own, operate or lease an aircraft/watercraft?

Yes No

04 ) Do you handle, treat, store, apply, dispose or transport hazardous material?

Yes No

05 ) Do you perform work underground or above 15 feet?

Yes No

06 ) Do you perform any work on barges, vessels, docks or bridge over water?

Yes No

07 ) Are you engaged in any other type of business?

Yes No

08 ) Do you hire subcontractors and/or independent contractors?

Yes No

09 ) Do your employees receive tips/gratuities?

Yes No

10 ) Do you sublet work without certificates of insurance?

Yes No

11 ) Do you provide any group transportation or delivery?

Yes No

12 ) Do you hire part time or seasonal employees?

Yes No

13 ) Do you have any volunteer or donated labor?

Yes No

14 ) Do any employees travel out of state?

Yes No

15 ) Do you offer health insurance?

Yes No

16 ) Do you have any anticipated debt or unpaid premiums owed to any previous workers’ compensation provider?

Yes No

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