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Workers compensation application

Workers compensation application

Questions? Call +1.800.995.1012
Monday – Friday, 8:30 a.m. – 5:00 p.m. EST

Please note: There is no option to save the form, so please have all information ready when you begin.

Fields with an asterisk (*) are required.

Named insured

DBA

Primary contact name

Phone number

Mailing address

City

State

Zip

Website address

Years in business

Are you an agent?

Agency name

Producer contact name

Producer email address

Are you a business owner?

Business contact name

Email address

Please note that Markel can send most insurance documents by email. Please provide a valid email address if you wish to receive your documents electronically.

FEIN #

PCRB # (PA Only)

Type of Entity

Title/Relationship

Ownership %

Duties

Inc/Exc

Payroll

Add more individuals

Name

Title/Relationship

Ownership %

Duties

Inc/Exc

Payroll

Add more individuals

Name

Title/Relationship

Ownership %

Duties

Inc/Exc

Payroll

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Name

Title/Relationship

Ownership %

Duties

Inc/Exc

Payroll

Rating information

Job duties

# of full time employees

# of part time employees

Estimated annual payroll

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Job duties

# of full time employees

# of part time employees

Estimated annual payroll

Add more ratings

Job duties

# of full time employees

# of part time employees

Estimated annual payroll

Add more ratings

Job duties

# of full time employees

# of part time employees

Estimated annual payroll

Prior carrier information/loss history (Need if submitting new business ONLY)

Year

Carrier

Policy Number

Annual Premium

# of Claims

Amount Paid

Add more prior carriers

Year

Carrier

Policy Number

Annual Premium

# of Claims

Amount Paid

Add more prior carriers

Year

Carrier

Policy Number

Annual Premium

# of Claims

Amount Paid

Add more prior carriers

Year

Carrier

Policy Number

Annual Premium

# of Claims

Amount Paid

General information

Does applicant own, operate or lease aircraft/watercraft? Yes No

Do/Have past, present or discontinued operations involve(d), storing, treating, discharging, applying, disposing or transporting of hazardous material? Yes No

Any work performed underground or above 15 feet? Yes No

If Yes, describe how many feet above or below ground is performed

Any work performed on barges, vessels, docks, bridges over water? Yes No

Is applicant engaged in any other type of business? Yes No

Are sub-contractors used? Yes No

If yes, what % of work subcontracted?

What type of work is subcontracted?

Any work sublet without certificates of insurance? Yes No

If yes, payroll for this work must be included in the rating information

Is a written safety program in operation? Yes No

Any group transportation provided? Yes No

Any employees under 16 or over 60 years of age? Yes No

If Yes, How many are under 16?

Over 60?

What are their job duties?

Any seasonal employees? Yes No

Is there any volunteer or donated labor? Yes No

If yes, please specify:

Any Employees with Physical handicaps? Yes No

Do Employees travel out of state? Yes No

If yes, indicate state(s) of travel:

% of time traveling:

Are atheltic teams sponsored? Yes No

Are physicals required after offers of employment are made? Yes No

Any other insurance with this insurer? Yes No

Any prior coverage declined/cancelled/non-renewed in the last three years? Yes No

Are employee health plans provided? Yes No

Do any employees perform work for other businesses or subsidiaries? Yes No

Do you lease employees to or from other employers? Yes No

Do any employees predominately work at home? Yes No

If yes, number of employees:

Any tax liens or bankruptcy within the last 5 years? Yes No

Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? Yes No

Has the insured had any lapse in workers compensation coverage? Yes No

Have employees been working without workers compensation coverage? Yes No

Is the insured aware of any claims/losses in the last 4 years? Yes No

Any work or locations outside of the state (mailing address state)? Yes No

Any employees travel over 200 miles? Yes No

Is this a newly established business? Yes No

Additional Information/Remarks: Please provide any additional details:

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