1 1 Policy Application

2 2 Application Summary

Sorry, we don't have availability to purchase it online, but we are working on it! In the meantime, please submit quote for underwriting and we’ll reach out with any remaining questions!

Limits of Insurance

Each Employee	$1,000,000
Disease Aggregate	$1,000,000
Disease Each Employee	$1,000,000

Initial payment: {[{ firstPayment|currency }]}
{[{ monthlyPayment.firstPaymentType }]}

We'll automatically charge your card {[{ monthlyPaymentAmount|currency }]}/mo for the next {[{ checkoutData.configuration.monthlyPaymentCount }]} months.

Switch to annual

Pay

Switch to monthly

Credit Card

[selected]

Billing Cycle

This field is required

Credit card information

Payment profile

Use different credit card

Card number

This field is required

Invalid credit card number

Please enter your credit card and bank information. Your credit card will be used for the down payment and your bank information will be used for the Capital Premium finance agreement monthly draft. If you have questions about alternative payment methods for the capital monthly draft please contact Capital Premium.

Expiration month

This field is required

Expiration year

This field is required

CVV

This field is required

Invalid cvv

Billing zip code

This field is required

Invalid ZIP code

Use this card later

This feature will create a customer payment profile for your billing information to allow easy checkout during future policy coverage extensions or updates. Credit card information is not stored within our system. All billing information is processed through authorize.net

EZ-Renew

With this beneficial feature your insurance coverage will be continuous without you worrying about having a lapse in your insurance policy.

You will receive a Conditional Renewal Notice prior to the renewal date of your policy. If you wish to cancel your policy, you must notify us in writing prior to the policy renewal date. You can cancel EZ-Renew at any time from your dashboard. Your policy will be renewed with the same coverage's, additional insureds and endorsements as your current policy. If you wish to change any coverages, you can login to your on-line account and make changes to your policy at any time.

Please note that we do NOT store credit/debit card numbers, nor do we share customer details with any third parties. Recurring billing is managed via Authorize.net.

Policy Holder Edit

, ,

Email:

Mobile number:

Physical Address is the Same as the Mailing Address

Physical Address:

, ,

Payment Information Edit

Payment Method:

Workers Compensation

Monthly Payment Breakdown

Policy start date: - Policy end date: Edit

If changes are needed, please reach out to your agent.

Edit

Limits of Insurance

Each Employee	$1,000,000
Disease Aggregate	$1,000,000
Disease Each Employee	$1,000,000

Policy Holder Business Information

Edit

Business Type
name
DBA
Mobile number
Website
Business Activities
Business Activities Description
Product Description

Owner Information

Edit

Owner's Full Name

Owner's Title

Are There Any Additional Owners?

Add. Owner's Full Name

Add. Owner's Title

Add. Owner's Full Name (2)

Add. Owner's Title (2)

Add. Owner's Full Name (3)

Add. Owner's Title (3)

Total Annual Owner's Payroll

Owner payroll amount will be adjusted subject to state minimum/maximums where applicable.

Do You Want to Include the Owner(s) in This Coverage?

Based on your selection, a state-specific owner inclusion/exclusion form will be completed for you regarding your response. To see this from, check you dashboard after purchasing.

General Eligibility

Edit

Which of These Business Activities Best Describes You?

Total Number of Employees

Total Number of Part-Time Employees

Total Number of Full-Time Employees

Total Annual Employee Payroll

Do You Have Any Seasonal Employees?

How Many Years Have You Been in Business?

What Is Your Employee Turnover Rate Each Year?

How Often Does the Business Clean Employee Work Areas?

Does the Business Have a Formal Written Safety Program?

Does the Business Offer Group Employee Health Insurance?

What % of Your Gross Sales Are from Alcohol?

Does the Business Deliver to Customers (Not Outsourced e.g. Uber Eats, DoorDash)?

What % of Your Gross Receipts Are From Food Delivery?

How Are the Delivery Employees Paid?

Do Delivery Employees Use a Motorcycle, Scooter or Bicycle?

Are all drivers are between the ages of 25 and 70 years old?

Does the Business Have a Safe Driver Eligibility Criteria Including Driver Eligibility Reviews?

What is the Business's Delivery Radius (in Miles)?

Delivery radius can't exceed 10 miles radius

Does the Business Provide Delivery Time Guarantees?

Does the Business Delivery of Alcohol?

Does the Business Operate a Food Truck?

How Many Stops Does the Food Truck Make in One day?

Do Employees Perform Duties Other Than Food Service (e.g. Event Set Up)?

Does the Business Operate Mobile Catering Services?

Does the Business Operate a Mobile Vending Cart?

Years of Experience in this Trade or Business?

Is the Business Open Between 11pm - 4:30am?

Does the Business Offer a Formal Orientation or Training Program?

Do You Sponsor Any Athletic Teams?

Do Any Employees Perform Work for Other Businesses or Subsidiaries?

Does the Applicant Own, Operate, or Lease Aircraft/Watercraft?

Are There Any Other Entities That You Own or Manage That Still Owe Undisputed Work Comp Premium to Anyone?

Any Tax Liens or Bankruptcy Within the Last Five (5) Years?

Any Work Performed on Barges?

Do You Lease Employees to or From Other Employers?

Is the Applicant Engaged in Any Other Type of Business?

Is There Any Volunteer or Donated Labor?

What Percentage of the Work Is Subcontracted?

If Employees Are Taken Out to Assist with Catering, What Is the Maximum Number of Employees That Would Travel in Any One Vehicle?

Insurance Information

Edit

Who Is Your Current Insurance Carrier?

Any Work Subcontracted to Others Without Certificates of Insurance?

How Long Have You Had Workers Comp Coverage?

Any Prior Coverage Declined, Canceled, or Non-Renewed in the Last Three (3) Years?

Prior Insurance

Claims History

Edit

How Many Losses Have You Had in the Past 4 Years?

If You Have Had a Loss in the Past 4 Years, Was Any Single Loss More Than $50,000?

Additional Insureds

Edit

Unlimited Additional Insureds

Additional Insureds

{[{ ai.name }]}

Employees

Edit

{[{ employee.firstName }]} {[{ employee.lastName }]}

+ {[{ optionalCoverage.employeePrice|currency }]}

Independent Contractors

Edit

{[{ contractor.firstName }]} {[{ contractor.lastName }]}

+ {[{ optionalCoverage.independentContractorPrice|currency }]}

Your policy will be issued and your documents available immediately after clicking the "Purchase Policy" button below. Your policy application may be subject to review by our underwriting team to verify that the business operation, product, and/or service meet the eligibility guidelines established for the program. In the event we need further clarification to determine eligibility, we will contact you via email at the email address used to establish your account. If an account is found to be ineligible during the underwriting period, the policy will be subject to immediate cancellation and a full refund will be issued. After the underwriting period, the premium is 100% earned and no refunds will be given.

Your agent will be contacting you soon. There is a pending document to be submitted.

Your form contains error(s). Please correct and try again.

An account with this email address already exists. Please login or change email address.

Due to some information provided, only submit for quote is available.

Quote only for this state.

Monthly Annual

You have selected a monthly payment plan. This is how much you will pay per month.

You have selected an annual payment plan. This is how much you will pay annually.

Order total

Workers Compensation

Policy Endorsements

Additional insureds

Unlimited

Cancel unlimited AIs

Coverage for Employees

Coverage for Independent Contractors

Loading... ^$

monthly

annually

monthly

^{DUE TODAY:} ^{(downpayment)}

Initial payment: {[{ firstPayment|currency }]}
{[{ monthlyPayment.firstPaymentType }]}

We'll automatically charge your card {[{ monthlyPaymentAmount|currency }]}/mo for the next 9 months.

Workers Compensation Policy

When do you want your policy to start?

About You

Business information

Mailing address

Physical Address

Owner Information

General Eligibility

Insurance Information

Claims History

Limits of Insurance

Initial payment: {[{ firstPayment|currency }]}
{[{ monthlyPayment.firstPaymentType }]}

Pay

Credit card information

EZ-Renew

Policy Holder Edit

Payment Information Edit

Workers Compensation

Limits of Insurance

Policy Holder Business Information

Owner Information

General Eligibility

Insurance Information

Claims History

Additional Insureds

Employees

Independent Contractors

Order total

Policy Endorsements

Additional insureds

Coverage for Employees

Coverage for Independent Contractors

Initial payment: {[{ firstPayment|currency }]}
{[{ monthlyPayment.firstPaymentType }]}

Workers Compensation Policy

When do you want your policy to start?

About You

Business information

Mailing address

Physical Address

Owner Information

General Eligibility

Insurance Information

Claims History

Limits of Insurance

Initial payment: {[{ firstPayment|currency }]} {[{ monthlyPayment.firstPaymentType }]}

Pay

Credit card information

EZ-Renew

Policy Holder Edit

Payment Information Edit

Workers Compensation

Limits of Insurance

Policy Holder Business Information

Owner Information

General Eligibility

Insurance Information

Claims History

Additional Insureds

Employees

Independent Contractors

Order total

Policy Endorsements

Additional insureds

Coverage for Employees

Coverage for Independent Contractors

Initial payment: {[{ firstPayment|currency }]} {[{ monthlyPayment.firstPaymentType }]}

Sign Here

Initial payment: {[{ firstPayment|currency }]}
{[{ monthlyPayment.firstPaymentType }]}

Initial payment: {[{ firstPayment|currency }]}
{[{ monthlyPayment.firstPaymentType }]}