1 1 Policy Options

2 2 Application Form

3 3 Additional Insureds

4 4 Payment, Review & Submit

Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting and we’ll reach out with any remaining questions!

Policy start date

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Policy end date

This policy will go into force on the start date and stay in force for 12 months.

Payments for this policy will stay in effect until cancelled.

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Please enter valid email address

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Confirm Email

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Email address should match

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Password

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Password must be at least 8 characters long and should contain at least one capital character, one lowercase character and one number.

Confirm Password

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Password should match

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Physical Address

First name

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Name can be between 2 and 70 characters long and can contain letters, hyphens, commas, dots, apostrophes and spaces

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Last name

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Name can be between 2 and 70 characters long and can contain letters, hyphens, commas, dots, apostrophes and spaces

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Street address

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WE CANNOT ACCEPT A PO BOX AS A PHYSICAL ADDRESS. KINDLY ENTER A PHYSICAL ADDRESS FOR YOUR BUSINESS.

You must own the business to purchase the insurance policy. We identify that this business name is disallowed from purchase.

Address line 2

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City

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State

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Please click here to be directed to an application that is specifically for those whose business is in .

Quote only for this state.

Due to the natural disaster in your area, We are unable to provide a policy to purchase for your selected effective date, please go back to this option and select a date that is available to you. We will begin selling same day policies again in your state when the memorandum has been lifted.

Zip code

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Invalid physical ZIP code

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Mailing Address is the Same as the Physical Address

Your state and zip code are invalid. Please edit your address. Suggested state:

Mailing address

Street address

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Address line 2

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City

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State

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Quote only for this state.

Zip code

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Business information

Business type

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Business Name

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Business name - Only letters(A-Z), numbers(0-9), &(ampersand), -(hyphen), '(apostrophe), .(dot), comma, ()brackets, spaces, ‘ ’(curly apostrophes), /(slash), :(colon), ;(semicolon) are allowed.

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Please provide your full name under mailing address.

A business you own and operate, not a business that employs you.

DBA

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Fein number

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Incorrect number format

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Mobile number

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Invalid phone

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Website

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Business activities

Janitorial/Commercial Cleaning (No Window Washing)

Landscape Gardening - All Operations

Primary Business Activity

Secondary Business Activities

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Describe other business activities

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Limits of Insurance

Coverage maximums - ensure they meet your state’s requirements.

Each Employee	$1,000,000
Disease Aggregate	$1,000,000
Disease Each Employee	$1,000,000

When you add a person^†, event, or organization to your policy as an additional insured, they receive protection if they are named in a suit due to a covered business-related loss/claim because of your actions or operations.

† Additional insured status cannot be granted to a friend or co-worker as an extension of your policy. Each individual must purchase their own policy to obtain liability coverage.

† A written contract, such as a venue, studio rental, or employment contract is required to add another party as additional insured.

Payment information

Initial payment:

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Pay

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Credit Card

[selected]

Credit card information

Payment profile

Use different credit card

Card number

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Please enter your credit card and bank information. Your credit card will be used for the down payment and your bank information will be used for the Capital Premium finance agreement monthly draft. If you have questions about alternative payment methods for the capital monthly draft please contact Capital Premium.

Expiration month

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Expiration year

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CVV

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Invalid cvv

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Billing zip code

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Use this card later

This feature will create a customer payment profile for your billing information to allow easy checkout during future policy coverage extensions or updates. Credit card information is not stored within our system. All billing information is processed through authorize.net

Order summary

Policy Holder Edit

, ,

Email:

Mobile number:

Mailing Address is the Same as the Physical Address

Mailing Address:

, ,

Payment Information Edit

Payment Method:

Workers Compensation RC Replica

Payment Breakdown

Policy start date: - Policy end date: Edit

If changes are needed, please reach out to your agent.

Edit

Limits of Insurance

Coverage maximums - ensure they meet your state’s requirements.

Each Employee	$1,000,000
Disease Aggregate	$1,000,000
Disease Each Employee	$1,000,000

Policy Holder Business Information

Edit

Business Type
name
DBA
Mobile number
Website
Business Activities
Business Activities Description
Product Description

Owner Information

Edit

Owner's Full Name

Owner's Date of Birth

Owner's Title

Are There Any Additional Owners?

Add. Owner's Full Name

Add. Owner's Title

Add. Owner's Full Name (2)

Add. Owner's Title (2)

Add. Owner's Full Name (3)

Add. Owner's Title (3)

Total Annual Owner's Payroll

Owner payroll will be adjusted based on state minimum/maximums, as applicable.

Do You Want to Include the Owner(s) in This Coverage?

Based on your selection, a state-specific owner inclusion/exclusion form will be completed for you regarding your response. To see this from, check your dashboard after purchasing.

General Eligibility

Edit

Which of These Business Activities Best Describes You?

Years of experience in this trade or business?

Total Number of Employees

Total Annual Employee Payroll

Do You Have Any Seasonal Employees?

How Many Years Have You Been in Business?

What Is Your Employee Turnover Rate Each Year?

How Often Does the Business Clean Employee Work Areas?

Does the Business Have a Formal Written Safety Program?

Does the Business Offer Group Employee Health Insurance?

Does the Business Offer a Formal Orientation or Training Program?

Do You Sponsor Any Athletic Teams?

Do Any Employees Perform Work for Other Businesses or Subsidiaries?

Does the Applicant Own, Operate, or Lease Aircraft/Watercraft?

Are There Any Other Entities That You Own or Manage That Still Owe Undisputed Work Comp Premium to Anyone?

Any Tax Liens or Bankruptcy Within the Last Five (5) Years?

Any Work Performed on Barges?

Do You Lease Employees to or From Other Employers?

Is the Applicant Engaged in Any Other Type of Business?

Is There Any Volunteer or Donated Labor?

What Percentage of the Work Is Subcontracted?

Tell us a little more about your business

Edit

Does the business do window, power washing or other exterior work off the ground?

Does the business perform any disaster recovery, mold remediation, fire or water restoration, hazardous or biohazard materials, or construction clean-up?

Does the business perform any landscaping or maintenance on public highways?

Does the business plant trees over 20ft tall?

Does the business engage in installation of pools or ponds?

Does the business do any tree trimming or removal requiring work above ground level?

Insurance Information

Edit

Who Is Your Current Insurance Carrier?

How long has the business had continuous coverage?

Any Work Subcontracted to Others Without Certificates of Insurance?

Please indicate why workers compensation coverage is being requested at this time.

Please provide further details on why you are requesting coverage at this time

Any Prior Coverage Declined, Canceled, or Non-Renewed in the Last Three (3) Years?

Underwriting Information

Edit

Does the business have any OSHA violations in the past 3 years?

Claims History

Edit

How Many Losses Have You Had in the Past 4 Years?

If You Have Had a Loss in the Past 4 Years, Was Any Single Loss More Than $50,000?

Additional Insureds

Edit

Unlimited Additional Insureds

Additional Insureds

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Employees

Edit

{[{ employee.firstName }]} {[{ employee.lastName }]}

Independent Contractors

Edit

{[{ contractor.firstName }]} {[{ contractor.lastName }]}

Your policy will be issued and your documents available immediately after clicking the "Purchase Policy" button below. Your policy application may be subject to review by our underwriting team to verify that the business operation, product, and/or service meet the eligibility guidelines established for the program. In the event we need further clarification to determine eligibility, we will contact you via email at the email address used to establish your account. If an account is found to be ineligible during the underwriting period, the policy will be subject to immediate cancellation and a full refund will be issued. After the underwriting period, the premium is 100% earned and no refunds will be given.

Your agent will be contacting you soon. There is a pending document to be submitted.

Coupon

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Discount applies to Additional Insureds only!

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Your form contains error(s). Please correct and try again.

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You need a policy that's as unique as your business. After your quote is submitted, one of our sales agents will contact you within 48 hours to complete your quote.

We noted you have made changes to the application you previously submitted. After clicking SUBMIT FOR QUOTE, your application will be sent again for our team to review.

Please click here to be directed to an application that is specifically for those whose business is in .

Quote only for this state.

Annual

Order total

Workers Compensation RC Replica

Policy Endorsements

Additional insureds

Unlimited

Cancel unlimited AIs

Coverage for Employees

Coverage for Independent Contractors

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This will be your recurring monthly payment after today. We will automatically charge your card each month.

monthly

^{DUE TODAY:} ^{(downpayment)}

Physical Address

Mailing address

Business information

Primary Business Activity

Secondary Business Activities

Limits of Insurance

Owner Information

General Eligibility

Tell us a little more about your business

Insurance Information

Underwriting Information

Claims History

Payment information

Initial payment:

Pay

Credit card information

Order summary

Policy Holder Edit

Payment Information Edit

Workers Compensation RC Replica

Limits of Insurance

Policy Holder Business Information

Owner Information

General Eligibility

Tell us a little more about your business

Insurance Information

Underwriting Information

Claims History

Additional Insureds

Employees

Independent Contractors

Order total

Policy Endorsements

Additional insureds

Coverage for Employees

Coverage for Independent Contractors

Sign Here