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Online Application

Please complete all of the fields as accurately as possible. Additional information may be required (we will contact you).

An underwriter will contact you within 24 hours.

 

ALL Questions must be answered in order to obtain a Quote

Thank you for your interest!

    
Business Name
Address:
City
State
Zip
County :
Business Contact Name
Business Phone:
Email
 
Legal Entity:(LLC, INC, DBA ECT)
Date Business was established
Federal Employer ID # :
Does the total payroll exceed $1 Million? Yes
 
Coverage Effective Date
Type of Business
Number of Prior Work Comp Losses in the Prior 3 completed policy years and the current year-to-date.
Prior Work Comp Insurance Company
Limit of insurance desired (if known)
Enter all states with locations to be included on this policy
Total Number of Employees
Please separate employee type (i.e. Clerical, cashier, doctor, etc.) and the corresponding annual payroll  
Postion Annual Payroll
Postion Annual Payroll
Postion Annual Payroll
Postion Annual Payroll
Postion Annual Payroll
Postion Annual Payroll
Postion Annual Payroll
Additional Comments
AGENCY INFORMATION IF APPLICABLE
Agency Name:
Contact's First Name:
Contact's Last Name:
Phone:
FAX:
Email:
Address:
State:
Zip:
    
   

COMPLETION OF THIS FORM CONSTITUTES PERMISSION FOR WORLDWIDE INSURANCE SPECIALISTS INC. TO OBTAIN CONSUMER INFORMATION WHICH WILL BE USED TO DETERMINE BONDING ELIGIBILITY. THIS INFORMATION WILL BE HELD IN THE STRICTEST CONFIDENCE