Request a Quote

 

We quote workers’ compensation through independent insurance agents. Please fill out the Contractors’ Supplemental Application below and we will contact your agent directly, or you can request that your agent send us a submission for a quote. If you do not have an agent, please contact us and we would be happy to assist you!

 
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Estimated Number of Employees AND Estimated Annual Revenue
Estimated Number of Employees AND Estimated Annual Revenue
Is your company licensed as:
Please provide a percentage for each
Please provide a percentage for each
Does your work require USL&H or FELA coverage? *
What pre-employment practices do you utilize in hiring personnel? *
Do you utilize workers provided by temporary staffing/leasing agency? *
Does this person have other roles besides implementing the safety program? *
How often are toolbox meetings held: *
Please check any type(s) of drug testing required of employees: