WC App | Witkin Insurance

Applicant Information

First name

Last name

Email

Phone

Business Information

Business Legal name

This Business uses a Doing Business As (DBA) name

What is the Business' Primary Industry

Business' Physical Address (Not a PO box)

Does the Business Have any Employees other than the owner/s?

Yes

No, just the owner/s

How many employees including Owner/s?

Where does your business Operate

Does your business own or lease any of the following?

Vehicles

Furniture

Inventory or Stock

Tools or Equipment

When do you want your policy to start?

What year was your business started?

How is your business structured?

What is the total annual payroll for W-2 employees (if any)? (exclude business owners/officers)

How many owners/officers do you want to cover with this policy?

Provide the first and last names of any covered/excluded officer/s

In the past 3 years how many Workers' Compensation claims were reported?

Do you have multiple locations in more than one state?

Yes

No

Do you currently have a Workers' Compensation insurance policy in effect?

Yes

No

Workers Comp Policy
Application