Workers Compensation Insurance Application

  • Additional Information

    In order to complete the underwriting process, the following items are needed for review. Once these are completed, a proposal can be generated. You can save the form and continue later if you don’t have all of the requested documents at the moment.

    • Completed Request for Proposal – Please download, fill out, and upload the Request for Proposal.
    • Completed Acord Application – Please download, fill out, and upload the Acord Application. California businesses please complete the California Acord Application.
    • 5 Years of Carrier-Supplied Workers’ Compensation Loss Runs – Please upload documentation.
    • Current plan and a current invoice.
    Drop files here or
    Max. file size: 128 MB.
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