Skip to content
Resources
About Us
FAQ
Blog
Request a Certificate
File a Claim
Agent Login
Resources
About Us
FAQ
Blog
Request a Certificate
File a Claim
Agent Login
Scroll to Top
Agency Name
Agency Contact
Email Address
Phone Number
Submit
Are You an Agent?
Yes
No
Get a Quote
Fill out the form below, and we will be in touch shortly.
Contact Information
Full Name*
Phone*
Email*
Business Information
Business Name*
Years In Business*
FEIN or SSN*
Legal Structure of Your Business*
Corporation
Partnership
Limited Liability Company
Sole Proprietorship
Other
Number of Employees*
Primary Address of Business*
Business Class Code(s) (Add as Many As Needed)*
Policy Information
Do You Want to Include Owners/Officers?*
Yes
No
Policy Effective Date*
Does Your Business Current Have Work Comp?*
Yes
No
How Long Has Your Business Had Work Comp?*
Has Your Business Had Any Work Comp Claims in the Past 3 Years?*
Submit
Become an Agent
Fill out the form below, and we will be in touch shortly.
Contact Information
Agent Full Name
Agency Name
Agency Address
Agent Phone
Agent Email
Please upload the following documents:
Agent License
Agency License
W-9 Form
E & O Coverage Verification
Submit
