Workers’ Compensation Insurance Quote Step 1 of 3 33% Company InformationFull Company Name*EIN/Tax ID*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website Contact InformationContact Name* Email* Phone* Workers' Comp informationWorkers' Comp Class Code and Payroll Amount (add more classes by clicking the + button)Class CodeEstimated Annual Payroll Who is your current Workers' Comp provider? (if none please enter N/A)*Are owner's included or excluded from this policy?*IncludedExcludedAre valid exclusions filed with the state?YesNoPlease list all owners that exlcuded. (use the + button to add more) Please list the owners that are to be included's information below. (use the + button to add more)Owner NameClass CodeAnnual Wages Any losses in the previous 3 years?YesNoPlease upload up to 3 years of previous loss runs if you have them.Accepted file types: jpg, pdf, png, bmp, gif.acceptable file formats: jpb, pdf, png, bmp, gifAre you receiving either of the following discounts? Drug Free Workplace Workplace Safety Credit Detailed description of operations.*Message / Comments Δ This iframe contains the logic required to handle Ajax powered Gravity Forms. Column 2/5