Business Information

Tell us about your business so we can find the best coverage options.

Legal Business Name * Please enter your business name

DBA (if applicable)

Business Address *

Please enter your business address

City *

State *

ZIP Code *

Business Phone *

Business Email *

Contact Name *

Contact Title

Website (if applicable)

Federal EIN * Format: XX-XXXXXXX

Business Operations

Help us understand your business operations and coverage needs.

Entity Type *

Years in Business *

Describe Your Business Operations *

Primary Industry *

Number of Locations

List Your Additional Locations

Requested Effective Date *

Current EMR (if known) Experience Modification Rate (1.00 = average)

Do you have a formal safety program?

Yes, documented safety program Informal safety practices No formal program

Briefly Describe Your Safety Program / Practices

Do you use subcontractors?

Yes No

Annual Cost of Subcontractors

Do You Collect Certificates of Insurance from Subs?

Washington State Note: Washington uses a state-managed workers' compensation fund through the Department of Labor & Industries. We can help you understand your options and ensure compliance with state requirements.

Payroll Information

Provide estimated annual payroll by employee classification. This helps us calculate accurate premium estimates.

Total Number of Employees *

Total Annual Payroll *

Payroll Breakdown by Classification

Add each job classification with estimated annual payroll. If you don't know your class codes, describe the job duties and we'll help identify the correct codes.

Job Classification / Duties	Class Code (if known)	# of Employees	Annual Payroll	Full/Part Time

Officers/Owners to Include or Exclude Some states allow officers/owners to opt out of coverage. Include names, titles, and ownership percentages.

Loss History

Please provide your workers' compensation claims history for the past 5 years. This information helps us find the best rates.

Current Insurance Carrier (if any)

Current Policy Expiration Date

Current Annual Premium

5-Year Claims History

Please provide claim information for each of the past 5 years. Enter $0 if no claims for that year.

Policy Year	# of Claims	Total Incurred	Total Paid	Open/Closed

You reported one or more claims above — please give us the details:

Claim Details (especially claims over $25,000)

Upload Loss Runs or Experience Mod Worksheet (recommended — requires Web3Forms Pro)

Click to upload or drag and drop

PDF, DOC, or XLS file up to 5MB

Review & Submit

Please review your information and add any additional comments before submitting.

Additional Information or Special Requests

How did you hear about First Underwriters?

Preferred Contact Method

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Best Time to Reach You

Morning (8am-12pm) Afternoon (12pm-5pm) Anytime

Privacy Notice: Your information is secure and will only be used to provide you with insurance quotes. We do not sell or share your personal information with third parties for marketing purposes. By submitting this form, you consent to be contacted regarding your insurance needs.

I certify that the information provided is accurate to the best of my knowledge and authorize First Underwriters Insurance Brokers to obtain additional information as needed to provide a quote. *

Workers' Compensation Insurance Quote

Business Information

Business Operations

Payroll Information

Payroll Breakdown by Classification

Loss History

5-Year Claims History

Review & Submit

Quote Request Submitted!

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