Hendrickson Insurance · Sarasota, Florida

Workers’ comp application.

For Florida Gulf Coast employers in Sarasota, Bradenton, Tampa, St. Petersburg, and the surrounding area, this helps us prepare a workers’ compensation quote for your business. Estimates are fine where you are not sure.

A. Business Information

Legal / Named Insured *

Required.

DBA (doing business as)

FEIN

Website

Contact name *

Required.

Phone *

Required.

Email *

Enter a valid email.

Primary location address *

Required.

City

State

ZIP

# of locations

Years in business

B. Operations & Payroll

Describe your operations / what you do *

Required.

Industry / NAICS or class code (if known)

# full-time employees

# part-time employees

Total annual payroll

States of operation

# of owners / officers

C. Employees & Class Codes

List job duties and payroll by class if known

Percent of work subbed and do you collect certificates of insurance?

D. Experience & Safety

Current experience modification factor

E. Prior Coverage & Loss History

Current WC carrier

Policy expiration date

Years continuously insured

List date, type, amount

F. Coverage Requested

Employers liability limits requested

Requested effective date

G. Acknowledgement

I certify that the information above is true and complete to the best of my knowledge. Submitting this form does not bind coverage; coverage is subject to underwriting approval and payment of premium.

Typed signature (full name) *

Required.

Date *

Required.

I agree to the statement above. *

Please confirm to submit.

Back

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Thank you — application received

Dennis will review it and follow up shortly with your quote. Questions? Call or text 941-957-2796.

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Please try again, or call/text 941-957-2796 and we’ll take your details directly.