Quick Quote

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Quote ID

autopopulated as uuid
Getting Started

Provide the following details requested below.
Account Name

Use a unique name for the account. If the name matches a prior entry, it may result in duplicate class, rate data being populated.
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Rating State
Select the primary state where the business operates.
Rating State*
Select the primary state where the business operates.

State
Ineligible State

States currently available for rating are AL, AZ, AR, GA, IN, IA, KS, KY, LA, MS, MO, NJ, NM, NC, OK, PA, SC, TN, & VA.
More states coming soon.
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Classes and Rates

Class Code	Class Rate	Payroll	Actions

There are no Classes.

Subtotal- Hidden
Price: $0.00
Experience Mod*
Please enter a number from .5 to 3.0.
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Total
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15% Down Pymt
Subject to carrier billing options
Premium Estimate

Annual Premium Down Payment

These are estimates only and not fully underwritten premiums.
Complete the submission for UW review and debits or credits.

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Child Entry ID 1
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Child Entry ID 2
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Child Entry ID 3
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Industry
Industry selection is important for triggering the proper UW questions and supplements.
Industry Type*
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User Class Description 1
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Class 1 Description (For Admin View)
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User Class Description 2
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Class 2 Description (For Admin View)
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User Class Description 3
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Class 3 Description (For Admin View)
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Class Code 1 (Admin)
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Class Code 2 (Admin)
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Class Code 3 (Admin)
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Class 1 Payroll
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Class 2 Payroll
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Class 3 Payroll
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Total Payroll (Admin)
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Show or Skip next page

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Class 1
Click the arrow to the right to expand the section.

Choose Class Description(s)

Start typing a word in the field below to see possible class description matches.
Class 1 Description
Start typing a word or class code to narrow down the options.
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Employees and Payroll
Uninsured Subs, Employees & Payroll

Each person and their payroll should only be counted once. Only include those who DO NOT have their own insurance or state applicable exclusion.
Class 1 Full Time Employees
Class 1 Part Time Employees
Add another class code?
Class 2

Class 2 Description
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Class 2 Full Time Employees
Class 2 Part Time Employees
Add another class code?
Class 3

Class 3 Description
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Class 3 Full Time Employees
Class 3 Part Time Employees
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For this risk to be eligible in the quoted program, you must have $15,000 payroll in a trade class OTHER than 5606, 8810, 8742, etc.

Insured Subs
Total Annual Amount Paid to Insured Subcontractors*
Only include the total amount for all classes you will pay to subs who DO HAVE their own Workers Comp or a state approved exemption. If they DO NOT have their own insurance or state exemption, they must be included in the individual class selections on the first page.
Subcontractor %
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Subcontractor Labor?
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Subcontractor Labor?

Business History
Number of Years in Business*
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Number of Years with Prior Coverage
Describe the Owners Prior Experience*
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Prior Coverage
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Is there an experience mod?
- No
- Yes
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Experience Mod
Please enter a number from .6 to 2.0.
Is coverage currently lapsed?
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Total Amount of Claims in 3 Years
Paid and Reserve Dollars- NOT # of claims
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Total Amount of Claims in 5 Years
Paid and Reserve Dollars- NOT # of claims
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ARAP
1.0 is Default. If you’re unsure, do not change it.
Please enter a number from .6 to 2.0.
Risks
Do you, your workers, or uninsured subs perform any of the jobs listed below?*
- Yes
- No

Exterior Work over 2 Stories	Day Laborers
Chimney Cleaning	Roofing
USL&H or Jones Act	Work Performed on Airports or Aircraft
Welding	Work on Public Roadways
Siding Installation	Work Above 20 Feet
Pressure Washing	Gutter Installation

Underwriting Details

Please include as much detail as possible regarding these exposures.
Provide details for the risk description that applies in the previous question.*
Details will be used by the underwriter to determine eligibility.

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What other quotes are you interested in?
Multi-policy pricing may apply
- General Liability
- Commercial Auto
- Other Commercial Policies
- Personal Home Insurance
- Personal Auto Insurance
- None
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Estimates
RATE
You will be able to select a pay plan during the application process
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Selected Program Name
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Policy Selections
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Employers Liability- Each Injury per Person
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Employers Liability- Each Disease
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Employers Liability- Each Disease per Person
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Lead State

This field is for zapier notifications only.
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Adword/Keyword
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Lead Grade

Quick Quote

Getting Started

Rating State

Ineligible State

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Premium Estimate

Industry

Class 1

Choose Class Description(s)

Employees and Payroll

Uninsured Subs, Employees & Payroll

Class 2

Class 3

Section Break

For this risk to be eligible in the quoted program, you must have $15,000 payroll in a trade class OTHER than 5606, 8810, 8742, etc.

Insured Subs

Business History

Prior Coverage

Risks

Underwriting Details

Estimates

Policy Selections

Final Quote Details

Business Info

Contact Info

Additional Owner(s)

Additional Owner(s)

Underwriting Section

Underwriting Questions

SmartComp Waiver of Subrogation

SmartComp Refer Waiver of Subrogation

CIC Waiver of Subrogation

Waiver of Subrogation

Prior Policy Details

Subcontractors

Agent Info

Address

Contact