Contact Info

Company Information

Employee information

*Please enter the number of employees and cumulative annual payroll per job role

Additional info

Employers who supplemented their workers’ compensation insurance with voluntary benefits such as accident insurance saw a 51% decrease in claims volume?”

  • Step 1
  • Step 2
  • Step 3
  • Step 4

Section 1

Name

Phone

Email

Website

Section 2

Company Name

escription of operations

FEIN

Number of Employees

Subcontractor %

Current work comp carrier

Effective Date

Section 3

Job Description

# of employees

Estimated Annual Payroll

Section 4

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