Workers Compensation Insurance Quote

Company Name*

Address*

Street Address Address Line 2 City State ZIP Code

Is your mailing address the same as your business address?

Yes
No

Mailing Address

Street Address Address Line 2 City State ZIP Code

Business Start Year*

The year this business was established.

How many years of experience do you have in this industry?*

This refers to the total number of years of work experience in the business regardless of whether you own the business.

Projected annual revenue(next 12 months)

Website (Optional)

What form of business entity do you have?*

What's your industry type?

Primary Contact Info

With this information provided, a CoverWallet account will be created for you.

Name*

First Last

Email*

Phone*

Employees Details

Tell us about the awesome people you work with

Total Number of Owners (actively involved in business operations)

Number of Full-Time Employees (not including owners)

Number of Part-Time Employees (not including owners)

Projected Employee Payroll(not including owners) for next 12 months

Worker's Compensation General Question

Are you a company or individual?

Company
Individual

FEIN (Optional)

We might be able to get you a quote without the FEIN, but we will eventually require it to bind it

SSN (Optional)

We might be able to get you a quote without the SSN, but we will eventually require it to bind it

Claims & Losses

Have you had any Workers' Compensation claims or losses in the last 5 years?

Yes
No

Please complete the following questions for each the Workers' Compensation claim or loss you have experienced in the past 5 years

Date of Occurrence

Type of claim or loss

Medical
Indemnity
Both

Description of claim or loss

Claim Status

Open
Closed

How much has been paid for this claim or loss?

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General Liability

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Many business like yours need General Liability for commercial leases or client contracts. Our median premium for your industry is $385.00.

Professional Liability

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Professional Liability covers the lawsuits for work mistakes and undelivered/negligent services. The median cost of a contract dispute is $91k.

Cyber Liability

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Cyber Liability can help your business survive a data breach and cyber attack by paying for recovery expenses. The average cost of small business data breach is $86k.

Umbrella Insurance

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Some contracts or leases require extra coverage. Umbrella Policy adds on protection in the case that your General Liability coverage is insufficient

Other Info

When would you like your policy to start?

Is there anything special we should know about your business or the specific coverage you need? For example, minimum insurance requirements or claims you've made in the last 3 years.

If you have a document with your insurance requirements you can attach it here.

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