Workers compensation application

Questions? Call 800-995-1012
Monday – Friday, 8:30 a.m. – 5:00 p.m. EST

All fields with a * are required.

Please note:

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

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.


Location 1 (if different from mailing address above)

Location 2

Location 3

Location 4

Location 5

Individuals Included/Excluded

Rating Information

Prior Carrier Information/Loss History (Need if submitting New Business ONLY)

General Information

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