Tell Us About Your Business

Legal Business Name *

DBA

Primary Physical Business Address (Not a PO Box) *

Legal Entity Type *

Federal ID Number *

Suite #

City *

State *

Zip *

Website

Who is Your Payroll Company?

Contact Information

Business Contact Name *

Business Contact Email *

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Main Business Phone Number *

Best Number to Call *

Describe Your Business Operations

Industry Type *

Would you like to add insurance coverage for owners, partners, or executives?

Policy Information

How long has the business had at least one employee, excluding owners and officers? *

Do you currently have Cyber Liability Coverage? *

Start Coverage Date *

Original Business Start Year (Estimated)

Do you currently have Workers' Compensation Coverage? *

Years of Workers' Compensation Coverage *

Do you have an Experience Modification (Ex-Mod or EMR)? *

Upload any policy documents, loss runs, census, etc.

Drop your file here or click here to upload You can upload up to 1 files.

Last STEP!

Has the business had ANY claims or work-related injuries in the past 4 years, or has an employee suffered a work-related injury requiring more than 2 days off work?

Does the business encrypt emails, mobile, and computing devices containing sensitive information sent to external parties?

Are you currently operating your business with employees and without Workers Compensation Insurance?

Any prior coverage declined / cancelled / non-renewed in the last three (3) years? (Not applicable in MO)

What percentage of your operations are subbed out to 1099s?

Does the business provide mandatory information security training to all employees at least annually? If not, is the business willing to implement it during the policy period?

Are you currently in bankruptcy or have you filed for bankruptcy?

Is this account a split risk/combinable with another risk?

Do operations include circuit board printing?

Does the business have a Designated Information Security Contact?

Does the business prevent unauthorized employees from initiating wire transfers?

Does the business verify vendor and/or supplier bank accounts before adding to accounts payable systems?

Does applicant own, operate or lease aircraft / watercraft?

Do the operations involve recyclying?

Has the business ever had any cyber insurance claim(s)?

Does the business store sensitive information online?

Does the business verify funds transfer requests, such as by calling a customer to verify the request at a predetermined phone number?

Any work sublet without certificates of insurance? (If “yes”, payroll for this work must be included in the state rating worksheet on page 2)

Phone

We use the information you provide, plus third-party data, to determine the best price for your business. Your information is confidential, secure and will not be shared or sold.

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