Workers' Compensation Insurance Quote - United Insurance Group

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Business Info

2

Employee Details

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Classifications

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Safety

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Contact

6

Review

Workers' Compensation Insurance Quote

Protect your business and employees with comprehensive workers' compensation coverage

Workers' Compensation Coverage

Workers' compensation insurance is required by law in most states if you have employees. It covers medical expenses and lost wages for employees injured on the job, and protects your business from lawsuits.

Business Information

Business Legal Name *

DBA (Doing Business As)

Federal EIN *

Business Entity Type *

Year Business Started *

Detailed Business Description *

Primary Industry/NAICS Code *

Business Locations

Primary Business Address *

City *

State *

ZIP Code *

Number of Locations *

States where employees work (Check all that apply) *

Ohio

Pennsylvania

Michigan

Indiana

West Virginia

Kentucky

Other States

Employee Information

Total Number of Employees * Include all W-2 employees

Full-Time Employees *

Part-Time Employees *

Seasonal Employees

Total Annual Payroll * Gross payroll before deductions

Overtime Payroll (Annual)

Are owners/officers to be included? *

Yes, include

No, exclude

Include some

Number of Owners/Officers

Owners/Officers Annual Payroll

Employee Classifications

List all job classifications and their payrolls. Be as specific as possible.

Class Code

Job Description

Number of Employees

Annual Payroll

Work Activities & Hazards

Do employees perform any of the following? (Check all that apply)

Work at heights (ladders, scaffolds, roofs)

Operate heavy machinery

Drive company vehicles

Handle hazardous materials/chemicals

Heavy lifting (over 50 lbs)

Underground work

Welding or torch work

Electrical work

Do you use subcontractors? *

No

Yes

If yes, do you require certificates of insurance from subcontractors?

Yes, always

Sometimes

No

N/A

Safety Program & Risk Management

Do you have a written safety program? *

Yes

No

In Development

Safety measures in place (Check all that apply)

Regular safety training

Safety meetings

Drug testing program

Required PPE

Return-to-work program

Safety incentive program

Type of drug testing performed (if applicable)

Pre-employment

Random

Post-accident

Reasonable suspicion

Claims History

Any workers' comp claims in the past 3 years? *

No

Yes

If yes, number of claims

Total claim amounts paid

Experience Modification Rate (if known) Leave blank if unknown or not applicable

Any OSHA violations or citations? *

No

Yes

Current Coverage Information

Current Workers' Comp Carrier

Current Annual Premium

Policy Expiration Date

Desired Coverage Start Date *

Contact Information

Contact Name *

Title/Position *

Email Address *

Phone Number *

Additional Information

Important Note

Workers' compensation rates vary significantly by state, industry, and job classification. An accurate quote requires detailed information about your business operations and employee duties.