Workers Comp & Disability Quote NY Workers Comp & Disability Legal Business Entity Name(Required) Business formation (LLC, Corporation, Sole Proprietor, etc)(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) FEIN # or Social Security #(Required) Contact Person's Name(Required) First Last Website Do you currently have Worker's Comp Coverage(Required) Yes No Current Insurance Carrier Expiration Date Annual Premium Have you had Worker's Comp coverage before? Yes No When was the last time Business Description(Required) Names of Owner(s)(Required) Add Remove# of employees(Required) Employee(s) Job Description(Required) Add Remove(office/clerical, outside sales, retail, carpentry, plumbing, etc)Annual Payroll(Required) Add RemoveTotal # of Male Employees(Required) Add RemoveTotal # of Female Employees(Required) Add RemoveDo you wish to include the owner(s)(Required) Yes No in the State of New York depending on how the business entity is formed owners can be either included or excluded from WC & Disability policiesOther NotesFileMax. file size: 39 MB.
