Workers Comp & Disability Quote

NY Workers Comp & Disability

Legal Business Entity Name(Required)

Business formation (LLC, Corporation, Sole Proprietor, etc)(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

FEIN # or Social Security #(Required)

Contact Person's Name(Required)

First Last

Website

Do you currently have Worker's Comp Coverage(Required)

Yes

Current Insurance Carrier

Expiration Date

Annual Premium

Have you had Worker's Comp coverage before?

Yes

When was the last time

Business Description(Required)

Names of Owner(s)(Required)

# of employees(Required)

Employee(s) Job Description(Required)

(office/clerical, outside sales, retail, carpentry, plumbing, etc)

Annual Payroll(Required)

Total # of Male Employees(Required)

Total # of Female Employees(Required)

Do you wish to include the owner(s)(Required)

Yes

in the State of New York depending on how the business entity is formed owners can be either included or excluded from WC & Disability policies

Other Notes

File

Max. file size: 39 MB.