First Name: * M.I.: 
Last Name: *
Title:  
Phone Number: * Ext:
Email Address: *
Legal Business Name:
   (Including DBA)
*
Street Address: *
   
City: *
State: *    Zip: 
Form of Business: *
Federal Employer Tax ID (FEIN):  
Or Social Security Number:  
Description of business operations:    
 
Has this business ever operated under another name? * Yes No
If yes, enter prior name:  
Please select all states where you have operations.
Are you in the temporary staffing or employee leasing business? * YesNo
In your business do you work from barges, boats, docks or on bridges over navigable water? * YesNo
In your business have you ever or do you plan to manufacture, install, remove, transport or dispose of asbestos? * YesNo
In your business have you ever or do you plan to store, treat, discharge, apply, dispose of, or transport hazardous materials? * YesNo
On what date would you like your coverage to begin?(MM/DD/YYYY; must be later than today's date, but no more than 90 days past today's date.) * /
 
Are you experienced rated? If unsure, select No. * Yes No
Are you merit rated? If unsure, select No. * Yes  No

Please select the industry group from the list below that best represents your business.
Professional and Office Occupations
  Engineering, Appraisals and Inspection
  Physicians Offices (Not Hospitals); Dentists Offices and Dental Labs
  Professional and Office Occupations
  Realtors, Salespersons and Messengers
Retail and Wholesale Stores
  Auto Dealers and Auto Leasing and Rental; Mobile Homes Dealers and Park Operators. 
  Automobile Service; Auto Tire & Accessories Stores; Gasoline Stations
  Building Material, Feed, Seed, Ice & Fuel Dealers
  Grocery & Food Stores - Retail and Wholesale
  Household Furnishings, Goods & Services - Retail and Wholesale
  Other Businesses
  Retail Stores
  Scrap Metal & Junk Dealers; Second Hand Material Dealers
  Wholesale Stores
Restaurants and Hotels
  Restaurants and Hotels
Commercial Services
  Building Maintenance and Operations by the Building Owner or Contractor
  Office Machines and Equipment - Sales and Service; Mail Services
Personal Services
  Barbershop, Beauty Parlor or Hair Styling Salon
  Clubs: Civic, Fraternal, Health, Private
  Entertainment, Recreation and Amusement Facility - Inside
  Entertainment, Recreation and Amusement Facility - Outside
  Funeral Homes and Cemetery Operations
  Laundry, Rug and Upholstery Cleaning
  Photographer
  Residential Services
  Stables, Kennels & Veterinary Services
  Theaters - All Kinds
Schools, Day Care and Churches
  Schools, Day Care, Churches and Charitable Organizations
Health Services
  Hospitals, Health Care Facilities, Nursing Homes
Printing, Publishing
  Printing, Bookbinding and Engraving
Trade Contractors
  Electrical Wiring, Alarm, Audio Systems
  Painting and Paper Hanging
  Plumbing, Sheet Metal and Partitions
Heavy Contruction
  Building Moving and Demolition
  Carpentry
  Concrete Construction
  Grading, Excavating, Clearing of Land or Dam Construction
  Installation of Machines and Equipment/Millwright Work
  Masonry and Plastering
  Oil/Gas/Water Drilling and Operations
  Other Construction: Fence Erection, Executive Supervisors, Yard
  Pile Driving
  Power Line, Electric Light or Communication Line Construction
  Railroad Construction
  Rigging/Structural and Ornamental Metal Erection/ Metal Doors/ Light Steel Frames
  Roofing and Waterproofing
  Sewers, Gas, Water Mains; Canals, Conduits and Subways
  Street and Road Construction
  Tunnels, Shafts and Caissons
  Welding
Food Products Manufacturing
  Bakery, Breakfast Food, Cracker, Macaroni and Other Products
  Bottling and Brewing Beverages - All Kinds
  Confections and Food Sundries
  Dairy Products
  Grain, Sugar, Syrup and Starch Products
  Meat and Seafood Products
  Preserving and Canning Food Products
  Tobacco Products
Cloth, Textiles and Clothing Manufacturing
  Clothing and Cloth Manufacturing
  Cotton Products
  Finishing of Textiles - Printing and Dyeing
  Fur and Leather Preparation
  Fur and Leather Products
  Headwear and Millinery Manufacturing
  Mattress or Box Spring - Bedding Manufacturing
  Other Cloth Products
  Other Textile Fabrics and Products
  Silk Products
  Wool Products
Wood, Paper and Plastic Products Manufacturing
  Barrels, Boxes and Veneer Products
  Furniture
  Linoleum, Oil Cloth and Imitation Leather
  Lumber Milling
  Other Wood Products
  Paper Goods Manufacturing
  Paper, Pulp, Fiber and Particle Board Manufacturing
  Pianos, Organs and Wood Musical Instruments
  Plastic Products
  Processing of Paper
  Rubber Products
Steelmaking, Metal Forming and Hardware Manufacturing
  Forging
  Foundries and Miscellaneous Pipe or Tube Manufacturing
  Hardware Manufacturing
  Plating
  Rolling Mills, Pipe or Tube, and Wire or Wire Rope Manufacturing
  Sheet or Stamped Metal Products
  Steelmaking, Ore Dressing, Smelting and Refining
  Structural and Ornamental Metal and Tank Fabrication
  Tool Manufacturing
  Wire Products Manufacturing
Petroleum, Chemical, Fertilzer and Paint Manufacturing
  Chemical Manufacturing
  Coal, Wood and Petroleum Products Manufacturing
  Explosives and Ammunition
  Fertilizer and Inorganic Material (Borax, Potash, Salt) Manufacturing
  Gases (Acetylene, Hydrogen, Oxygen) Manufacturing
  Ink, Paints, Wax and Polish Manufacturing
Manufacturing - Other
  Appliance & Electrical Components
  Asbestos and Mica Products Manufacturing or Abrasive Wheel Manufacturing
  Audio - Visual Products
  Automobile Bodies Manufacturing
  Brick, Clay or Tile Products Manufacturing
  Cement, Lime and Plaster Manufacturing
  Cement, Plaster and Concrete Products Manufacturing
  Clock, Measuring Instruments or Optical Goods Manufacturing
  Electrical Battery Manufacturing
  Glass, Mirror and Other Glass Products Manufacturing
  Glue, Lard Manufacturing from Animal By-Products
  Grinding, Milling, Cutting or Polishing of Minerals and Stone
  Jewelry, Silverware and Musical Instruments (Metal) Manufacturing
  Manufacturing of Machines & Machine Shops
  Miscellaneous Machined Products Manufacturing
  Miscellaneous Products
  Office Machines Manufacturing
  Pharmaceutical and Surgical Goods Manufacturing
  Pottery or Terra Cotta Products Manufacturing
  Sign Manufacturing, Painting and Installation
  Vegetable Oil and Soap Manufacturing
  Vehicles Manufacturing
Agriculture and Mining
  Agriculture, Livestock and Forestry
  Logging and Lumbering
  Mining
  Oil or Natural Gas Production
  Quarrying, Stone Crushing and Sand and Clay Digging
Transportation, Communications and Utilities
  Aircraft Operations
  Marine - Diving, Dredging and Wrecking
  Public Utilities
  Railroad Operation
  Ship and Boat Building and Maintenance
  Ships, Boats and Marinas Operations
  Stevedoring and Freight Handling
  Trucking, Taxi, Buses; Hauling Mail, Parcels, Beverages; Other
  Warehousing and Storage
Public Works; Governmental Sevices; Police and Private Security; Fire Departments
  Garbage Collection, Street or Sewer Cleaning and Snow Removal
  Governmental Services; Police and Private Security; Fire Departments
  Public Works Operations
Radio and Television Broadcasting, Motion Picture Production and News Paper Publishing
  Radio and Television Broadcasting, Motion Pictures and Newspaper Publishing

How many employees are at this location?
Square Footage of business
Business Income / Revenue
Previous Carrier
Prior Losses
Gross Payroll
Rating Information
Please answer the following rating information questions 
Limits of Liability for Employers Liability insurance:*
 
Each Accident
Each Employee
Policy Limit
1000000 1000000 1000000
500000 500000 500000
100000 100000 500000

 
How many workers compensation claims have you made in the last three years?
How many workers compensation claims over $2000 have you had in the last three years?
What are the estimated total costs of your workers compensation claims in the last three years?
How many years have you been in business?

 
Do any employees work from home? * Yes No
Select deductible amount:
NEW YORK *