Notice: The following states cannot be written through this program: AK, DE, HI, ND, OH, WA, WY.
Locations / Rating Information
Skip if you have no clerical staff
Skip if you have no vehicle drivers for your business
Each accident / Disease policy limit / Disease each employee
Owners, Partners, Officers, Relatives
Nature of Business / Description of Operations
Missouri applicants do not have to answer this.
APPLICABLE IN TENNESSEE AND VERMONT: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS’ COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, FL, HI, MA, NE, OH, OK, OR, TN OR VT) (DC, LA, ME, VA and WA, INSURANCE BENEFITS MAY ALSO BE DENIED)