Workers Compensation Insurance Quote Short Form What industry is the business in?Select--> NOT LISTED ACCOMODATION AND FOOD SERVICES Agriculture, Forestry, Fishing and Hunting Carpet and Upholstery Cleaning Services Caterers Drinking Places (Alcoholic Beverages) Employment Services Facilities Support Services Food Services and Drinking Places Investigation and Security Services Janitorial Services Landscaping Services Limited-Service Restaurants Office Administrative Services Other Services to Buildings and Dwellings ARTS, ENTERTAINMENT, AND RECREATION Amusement, Gambling, and Recreation Industries Performing Arts, Spectator Sports, and Related Industries CONSTRUCTION Drywall and Insulation Contractors Electrical Contractors Finish Carpentry Contractors Flooring Contractors Framing Contractors Glass and Glazing Contractors Masonry Contractors Nonresidential Building Construction Other Specialty Trade Contractors Painting and Wall Covering Contractors Plumbing, Heating, and Air-Conditioning Contractors Poured Concrete Foundation and Structure Contractors Residential Building Construction Roofing Contractors Siding Contractors Structural Steel and Precast Concrete Contractors Tile and Terrazzo Contractors Utility System Construction EDUCATIONAL SERVICES Elementary and Secondary Schools Sports and Recreation Instruction FINANCE AND INSURANCE Agencies, Brokerages, and Other Insurance Related Activities Insurance Carriers Investment Advice HEALTH CARE AND SOCIAL ASSISTANCE Child Day Care Services Home Health Care Services Hospitals Individual and Family Services Medical and Diagnostic Laboratories Nursing and Residential Care Facilities Offices of Chiropractors Offices of Dentists Offices of Mental Health Practitioners (except Physicians) Offices of Optometrists Offices of Physical, Occupational Speech Audiologists Offices of Physicians INFORMATION Internet Publishing and Broadcasting Internet Service Providers, Web Search, Data Processing Services Software Publishers Telecommunications MANAGEMENT OF COMPANIES AND ENTERPRISES Corporate, Subsidiary, and Regional Managing Offices MANUFACTURING Fabricated Metal Product Manufacturing OTHER SERVICES Automotive Repair and Maintenance Beauty Salons Business, Professional, Labor, Political, and Similar Organizations Car Washes Civic and Social Organizations Commercial/Industrial Machinery Equip Repair/Maint (not auto/elect) Diet and Weight Reducing Centers Electronic and Precision Equipment Repair and Maintenance Home and Garden Equipment and Appliance Repair and Maintenance Other Personal and Household Goods Repair and Maintenance Parking Lots and Garages Pet Care (except Veterinary) Services Private Households Religious Organizations Social Advocacy Organizations PROFESSIONAL, SCIENTIFIC AND TECHNICAL SERVICES Accounting, Tax Preparation, Bookkeeping, and Payroll Services Administrative Management General Management Consulting Advertising and Related Services Architectural Services Building Inspection Services Computer Systems Design and Related Services Engineering Services Environmental Consulting Services Human Resources and Executive Search Consulting Services Landscape Architectural Services Legal Services Marketing Consulting Services Other Management Consulting Services Other Scientific and Technical Consulting Services Other Specialized Design Services Photographic Services Scientific Research and Development Services REAL ESTATE AND RENTAL AND LEASING Lessors of Residential Buildings and Dwellings Offices of Real Estate Agents and Brokers Offices of Real Estate Appraisers Real Estate Property Managers RETAIL TRADE All Other General Merchandise Stores All Other Miscellaneous Store Retailers All Other Specialty Food Stores Automobile Dealers Automotive Parts, Accessories, and Tire Stores Clothing Stores Cosmetics, Beauty Supplies, and Perfume Stores Gift, Novelty, and Souvenir Stores Nonstore Retailers Sporting Goods Stores TRANSPORTATION AND WAREHOUSING All Other Support Activities for Transportation Couriers and Messengers General Freight Trucking, Local General Freight Trucking, Long-Distance Limousine Service Motor Vehicle Towing Other Support Activities for Transportation Other Transit and Ground Passenger Transportation Taxi Service UTILITIES Utilities WASTE MANAGEMENT AND REMEDIATION SERVICES Waste Management and Remediation Services WHOLESALE TRADE Apparel, Piece Goods, and Notions Merchant Wholesalers Wholesale Trade Agents and Brokers OTHER Please describe the nature of business: If currently insured, please select current insurance company:Not Insured AAA Insurance Co. AETNA AFLAC AIG AIU Insurance Allied Allstate County Mutual Allstate Indemnity Allstate Insurance American Alliance Insurance American Automobile Insurance American Casualty American Deposit Insurance American Direct Business Insurance American Empire Insurance American Family Insurance American Family Mutual American Financial American Home Assurance American Insurance American International Ins American International Pacific American International South American Manufacturers American Mayflower Insurance American Motorists Insurance American National Insurance American Premier Insurance American Protection Insurance American Republic American Savers Plan American Service Insurance American Skyline Insurance Company American Spirit Insurance American Standard Insurance - OH American Standard Insurance - WI Amica Insurance Arbella Associated Indemnity Assurant Atlanta Casualty Atlantic Indemnity Auto Club Insurance Company Blue Cross and Blue Shield Cal Farm Insurance California State Automobile Association Chubb Clarendon American Insurance Clarendon National Insurance CNA Colonial Insurance Company Not Listed Continental Casualty Continental Divide Insurance Continental Insurance Cotton States Insurance Country Insurance and Financial Services Dairyland County Mutual Co of TX Dairyland Insurance Electric Insurance Erie Insurance Company Erie Insurance Exchange Erie Insurance Group Erie Insurance Property and Casualty Esurance Farm Bureau/Farm Family/Rural Farmers Insurance Farmers Insurance Exchange Farmers TX County Mutual Farmers Union Fire and Casualty Insurance Co of CT Fireman's Fund Direct Casualty Direct General Insurance Direct Indemnity GMAC Insurance Golden Rule Insurance Government Employees Insurance Guaranty National Insurance Hanover Lloyd's Insurance Company Hartford Accident and Indemnity Hartford Casualty Insurance Hartford Fire Insurance Hartford Insurance Co of Illinois Hartford Insurance Co of the Southeast Hartford Omni Hartford Underwriters Insurance Health Plus of America HealthShare American IFA Auto Insurance IGF Insurance Infinity Insurance Infinity National Insurance Infinity Select Insurance Integon John Hancock Kaiser Permanente Kemper Lloyds Insurance Landmark American Insurance Leader National Insurance Leader Preferred Insurance Leader Specialty Insurance Liberty Insurance Corp Liberty Mutual Fire Insurance Liberty Mutual Insurance Liberty National Liberty Northwest Insurance Lumbermens Mutual Mass Mutual Mega/Midwest Mercury Metropolitan Insurance Co. Mid Century Insurance Mid-Continent Casualty Middlesex Insurance Midland National Life Mutual of New York Mutual Of Omaha National Ben Franklin Insurance National Casualty National Continental Insurance National Fire Insurance Company of Hartford National Health Insurance National Indemnity National Union Fire Insurance of LA National Union Fire Insurance of PA Nationwide General Insurance Nationwide Mutual Fire Insurance Nationwide Mutual Insurance Nationwide Property and Casualty New York Life Insurance Northwestern Mutual Life Northwestern Pacific Indemnity Omni Indemnity Omni Insurance Orion Insurance Pacific Indemnity Pacific Insurance Pafco General Insurance Patriot General Insurance Peak Property and Casualty Insurance PEMCO Insurance Progressive Progressive Auto Pro Prudential Insurance Co. Reliance Insurance Reliance National Indemnity Reliance National Insurance Republic Indemnity Response Insurance SAFECO Safeway Insurance Safeway Insurance Co of AL Safeway Insurance Co of GA Safeway Insurance Co of LA Security Insurance Co of Hartford Security National Insurance Co of FL Sentinel Insurance Sentry Insurance a Mutual Company Sentry Insurance Group Shelter Insurance Co. St. Paul St. Paul Fire and Marine St. Paul Insurance Standard Fire Insurance Company State and County Mutual Fire Insurance State Farm County State Farm Fire and Cas State Farm General State Farm Indemnity State Farm Insurance Co. State Farm Lloyds Tx State Farm Mutual Auto State National Insurance Superior American Insurance Superior Guaranty Insurance Superior Insurance The Ahbe Group TICO Insurance TIG Countrywide Insurance Travelers Indemnity Travelers Insurance Company Tri-State Consumer Insurance Twin City Fire Insurance UniCare United Pacific Insurance United Security United Services Automobile Association Unitrin Direct US Financial USAA USF and G Viking County Mutual Insurance Viking Insurance Co of WI Windsor Insurance Woodlands Financial Group Company Not Listed If currently insured, annual premium range: Select--> Not Insured Insured, but I dont know. $500 - 999 $1,000 - 2,999 $3,000 - 4,999 $5,000 - 9,999 $10,000 - 19,999 $20,000 - 49,999 $50,000+ Year or time frame business started: Select--> Just Starting Now Seasonal_Event One Time Event 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 or Earlier Owners years of experience in the business: Select--> less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 21+ Number of Owners and / or Partners: Select--> 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21+ Number of employees that work more than 30 hours a week: Select--> 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21+ Number of employees that work less than 30 hours a week: Select--> 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21+ Number of Sub-Contractors: Select--> 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21+ How many transactions to you process each month? Select--> 1-99 100-499 500-999 1000-2499 2500-4999 5000+ Do you have a bank account? What is your business legal entity? Select--> Corporation S Corporation Limited Liability Company Limited Liability Partnership Partnership Sole Proprietorship Limited Partnership Professional Corporation Nonprofit Corporation Other
