Workers Compensation Insurance Application, Fast Coverage

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Home
Commercial Insurance
- Business Coverages
- Specialty Industry Coverages
Contractual Risk Management
Bonds
Employee Benefits
DRONE(UAS) QUOTE
About
- About Us
- Blog
- Contact
PayNow

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Workers Compensation Application

Free Text

Section 1 of 2 - General Business Info

1. Business Entity Name*:

2. DBA:

3. Mailing Address*:

4. Physical Address:

5. Website

6. FEIN#*:

7. Year Business Started*:

8. Estimated Gross Annual Revenue*

Gross receipts for the last year

9. Main Contact Name and Title*:

10. Main Contact Email Address*:

11. Date of Renewal

12. Description of Operations*:

Free Text

Section 2 of 2 - Workers Compensation

Class Code*

Estimated Annual Payroll $*

Class Code

Estimated Annual Payroll $

Class Code

Estimated Annual Payroll $

1- Partners, Officers, Relatives - Name, DOB, Ownership %*

Include in coverage?*

YES

NO

2- Partners, Officers, Relatives - Name, DOB, Ownership %

Include in coverage?

YES

NO

Is a written safety program in operation?*

YES

NO

Do you use subcontractors?*

YES

NO

Annual Sub Contractor Costs*

Have there been any losses, claims or suits against you in the past 5 years?*

YES

NO

Notes or more data you would like to tell us about your business

Thank you for contacting us.
We will get back to you as soon as possible.

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Your business deserves more than just a policy—it deserves a partner. Let's discuss how Hako Risk & Insurance can help you minimize risks and maximize protection.

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Business Name:

Hako Risk & Insurance

Phone:

(844) 850-4400

Email:

customerservice@hakorisk.com

Doing business in California as Hako Risk & Insurance Services (License # 6006242)

Service Areas

AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY

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