To apply for coverage, please complete and submit the application below.

Fields indicated with an asterisk * are required.

Broker Submitting Quote Request

Licensed

YesNo

Agent ID

*

First Name

*

Last Name

Company

*

Phone

Extension

*

Email

Fax

Address

City

*

State

NYALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP

Employer Information

Employer Name: 

Address

City

State

NYALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP

Phone

Extension

Unemployment Insurance Number:

Unassigned

SSN or Federal Tax ID:

Mandatory

Form of Organization:  —Please choose an option—CorporationPartnershipSole ProprietorshipOther

Nature of Business: 

Number of employees to be insured:

Male

Female

Total

Desired Effective Date of Coverage: 

Previous DBL Carrier: 

Termination Date: 

Name of Workers Compensation Carrier: 

Insurance Company Desired: Standard SecurityWestCoGuardianShelterpoint

Additional employees to be Included as covered employees:

Remarks:

Please confirm: Do you wish to bind coverage?  —Please choose an option—YesNo

New to this website? We cannot bind coverage for you without a copy of your license.
Please fax a copy of your license to us at 631-265-7054.