Worker’s Compensation Quote The Workers’ Comp Mistake That Could Cost You Thousands — And How to Avoid It Starting Your First Policy? Avoid These Common Workers’ Comp Surprises BASIC BUSINESS INFORMATION Are you part owner of the business? No Yes Business Name * Business Structure * Sole Proprietor C Corporation S Corporation LLC Business Address * Business Phone * (###) ### #### Email * Federal Employer ID Number (FEIN) * Years in Business Nature of Business / Description of Operations * Website http:// Do you currently carry workers’ compensation insurance? * No Yes EMPLOYEE & PAYROLL INFO # Full-Time Employees * # Part-Time Employees * Estimated Annual Payroll * $ Class Code or Business Description * Do you have a written safety program? * No Yes Are employees working in clients’ homes or job sites? * No Yes Do you use subcontractors or 1099 workers? * No Yes Do employees use personal or company vehicles for work? * No Yes Do you hire any temporary, part-time, or seasonal workers? * No Yes PARTNERS, OFFICERS, RELATIVES (Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.) Exclusions in Missouri must meet requirements of Section 287.090 RSMo. Name * Date of Birth * MM DD YYYY Title / Relationship * Ownership % * Duties * Add a 2nd Officer * No Yes Add a 3rd Officer * No Yes Requested Effective Date MM DD YYYY Thank you!
