Year business started:
What is your business legal entity?
Corporation
S Corporation
Limited Liability Company
Limited Liability Partnership
Partnership
Sole Proprietorship
Limited Partnership
Professional Corporation
Nonprofit Corporation
What industry is your company in?
--Pick your industry--
--> CONTRACTORS
Janitorial Services
Air Conditiong Contractors
Cabinet Building & Installation
Cable Installation
Carpentry
Carpet Laying Installation
Ceramic Tile Installation
Commercial Fence Contractor
Drywall Installation Contractors
Electrical Wiring Contractors
Floor Covering Installation
Frame Contractors
General Contractor
Glass/Glazing Work Contractor
Heating Contractors
Landscaping
Masonry Contractor
Painting/Wallpapering
Plumbing Contractor
Residential Contractor
Roofers
Telephone Equipment Installation
Other Contracting-based Industry
--> OFFICE
Accountants/Bookkeepers
Advertising Agencies
Architects/Engineers
Chiropractors' Offices
Computer Consultants
Consultants
Doctors/Dentists/Medical Offices
Dog Grooming Shops
General Offices
Graphic Designer Offices
Inspection & Appraisal Services
Interior Designers/Decorators
Law Offices
Management Consultants
Manufacturers' Representatives
Publishing Offices
Real Estate Agents
Travel Agents
Veterinarians
Other Office-based Industry
--> SERVICES
Appliance Installation
Appliance Repair
Day Care
Dental Labs
Dry Cleaners
Funeral Directors
Locksmiths
Musical Instrument Repair
Nursing Homes
Office Machine Repair
Photocopying & Blueprinting
Photoengraving
Photographic Studios
Pool Maintenance
Printing (Commercial)
Printing (Instant Print & Duplic.)
Radio & TV (Retail & Repair)
Rehabilitative Services
Shoe Repair
Tailors
Taxidermists
Tour Services
Tow Trucks
Tree Services
Trucking
Other Service-based Industry
--> MANUFACTURING
Candy & Other Confec. Prod. Mfg.
Canned Specialties Mfg.
Computer Equipment Mfg.
Electronics Mfg.
Food Products Mfg.
Household Audio & Video Equip. Mfg.
Metal Mfg.
Metal Working Job Shops
Microbreweries Mfg.
Office and Store Fixtures
Partition and Shelves Mfg.
Office Machines Mfg.
Plastics Machines Mfg.
Radio and TV Comm. Equip. Mfg.
Tool and Die Patterns and Mold Mfg.
Other Manufacturing-based Industry
-->RETAIL/WHOLESALE
Appliance Stores
Automobile Dealerships
Automobile Parts
Bath Shops
Bars
Beauty Supplies
Books/Magazines Retail
Cameras & Supplies
Candy/Nut & Confectionery Stores
Carpet Retail
Clocks
Dance Clubs
Drug Stores
Electrical Supplies
Florists/Garden Shops
Gift/Souvenir Shops
Greeting Cards
Hardware Stores
Health Food Stores
Hearing Aids
Hobby Shops & Model Stores
Ice Cream Parlors
Optical Goods
Pet Shops & Pet Supplies
Picture Frames
Plumbing Supplies
Restaurant
Shoes
Sporting Goods
Tobacco
Toys
Trophies
T-shirt Shops
Video Tape Stores
Other Retail/Wholesale Industry
--> OTHER
Airboat Related
Alarms/Guards
Apartments
Churches & Synagogues
Coastal Property
Habitat
Horse Related
Import/Export
Marine
Non-Profit Organization
Oil & Gas
Parks
Water Related
Description of the work you business performs:
(Please be as detailed as possible)
Describe the job function of employees:
Your estimated yearly gross payroll:
SELECT --->
under $50,000
$50,000 - 99,999
$100,000 - 249,999
$250,000 - 499,999
$500,000 - 999,999
$1,000,000 - 4,999,999
$5,000,000 +
# of Full Time Employees:
--Pick--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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
51+
# of Part Time Employees:
--Pick--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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
51+
# of Subcontractors:
--Pick--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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
51+
How many years of experience does the owner of your business have in your industry?
--Pick--
Less than 1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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
51+
Do you currently have workmans compensation coverage?
If yes, what company?
Do you have employees that live outside of your business's state?
What is your NCCI experience modification factor?
Other information you think we should know:
Name of Business:
First Name:
Last Name:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Phone:
Fax:
Email:
PROMO CODE
