Worker’s Compensation Quote Form – Purely Insurance

Purely Worker's Compensation Application

This field is hidden when viewing the form
EZLynxAppID
Your Information

Your Name
First Last
Phone
Email*
Do you own 50% or more in another business?
Please describe other business ownership
Business Information

Business Name
Do you have a DBA Name (Doing Business As)*
What is your DBA Name?
Business Website
Business Entity Type*
- Individual (Sole Proprietor)
- Partnership
- Corporation
- LLC
- Other
What is the Business Tax ID?
What is your Social Security #?
What Entity Type is the Business?
What is the Business Tax ID or your Social Security #?
Business Physical Address
Street Address City State ZIP Code
Does the business use different Mailing Address?*
Business Mailing Address
Street Address Address Line 2 City State ZIP Code
Did you recently form the busines??*
What year did the business start?
How many years of experience do you have?
What is the total annual gross revenue or sales?
What is the first-year revenue or sales Forcast?
Briefly describe business operations*
Has any policy been cancelled or non-renewed in the past 3 years?
- Yes
- No
Describe reason for cancellation or non-renewal
Did you have any claims in the past 5 years?
- Yes
- No
Describe claims in the last 5 years with amount paid for each loss or claim.
Classification and Payroll Information

What is your Work Comp Policy Status?*
Do you have an establish Experience Modification?*
What is your current Ex-Mod?
Employee Classification and Payroll
Class Code Job Description # Full Time Employees # Part Time Employees Total Annual Payroll
Owner Exclusion or Inclusion*
Officer Name Title % Ownership Annual Payroll Include or Exclude
Does your business hire Sub Contractors?
Do you Require Work Comp Certificates from you Subs?
Are you listed as Additional Insurance on all Certificate from Subs??
General Questions

Do have any unsettled Work Comp Audits?*
Do you offer health insurance to your employees?*
Who is your Group Health Insurnace Company?
Do you have safety meetings?
Do you have a return to work program?
Do you do drug testing?
Additional Insurance Policy Information

Does your business have a General Liability Policy?
Does your business have a Product Liability Policy?
Does your business have a Professional Liaibilty Policy?
Does your business have a Commercial Auto Policy?
Comments

Is there anything specific that you would like us to know?
Upload Dec Pages or Loss Runs if applicable

Upload Documents
Drop files here or

Max. file size: 128 MB.

This field is hidden when viewing the form
contactId
This field is hidden when viewing the form
ownerEmail