Thank you for your inquiry for a Workers Compensation quote from Area Insurance Network, Inc.

The easiest way to complete this form, is to have your current Workers Comp policy available for certain data. 

Please take a few moments and complete as much of this online application as possible. Please note there are some required fields, they are denoted by a yellow * The more detail you can provide, the more accurate we can make your quote. If we need additional information, one of our specialists will contact you to obtain it. At the time of completing this online application, if you do not know an answer to a particular question, you may skip it and our specialist will obtain the information later in the process.

Company *             Applicant Name *   Office Phone *      

Mobile Phone Street Address       2nd Address

City   State     Zip    email *

Business Type: Please Select Sole Proprietor Corporation LLC Trust Partnership Sub Chapter S Corp Joint Venture Other    Locations:

Proposed effective date:                        Expiration date:

Anniversary Date:                            Retro Date:      

Workers Compensation State: Kentucky Ohio West Virginia

Employer's Liability:    Each Accident -

Rating Information   

Class Code    Rate    Empl Annual Salary

Class Code    Rate    Empl Annual Salary

Class Code    Rate    Empl Annual Salary

Please add any Additional Class Code Information:

Deductible

Experience Mod

Losses in last 3 years

Prior Carrier Information / Loss History. Upload Loss Runs  

NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS:

Give comments and descriptions of Business, Operations and Products:

Manufacturing - Raw Materials, Processes, Product, Equipment.

Contractor - Type of work, Sub-Contractors.

Mercantile - Merchandise, Customers, Deliveries.

Service - Type, Location.

Farm - Acreage, Animals, Machinery, Sub-Contracts.

General Information:

Explain all "YES" Responses

1.) Does Applicant own, operate or lease aircraft / watercraft?                     Please Select Yes No

2.) Do/Have Past, Present or Discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc)                                                                                                                                  Please Select Yes No

3.) Any work performed underground or above 15 feet?                                    Please Select Yes No

4.) Any work performed on barges, vessels, docks, bridge over water?                Please Select Yes No

5.) Is applicant engaged in any other type of business?                                    Please Select Yes No

6.) Are Sub-Contractors used? (If "Yes", give % of work subcontracted)                          Please Select Yes No

7.) Any work sublet without certificates of insurance?                                      Please Select Yes No

(If "Yes", payroll for this work must be included in the State Rating Worksheet on Page 2)

8.) Is a written safety program in operation?                                                  Please Select Yes No

9.) Any group transportation provided?                                                          Please Select Yes No

10.) Any employees under 16 or over 60 years of age?                                     Please Select Yes No

11.) Any seasonal employees?                                                                      Please Select Yes No

12.) Is there any volunteer or donated labor? (If "YES", please specify)                    Please Select Yes No

13.) Any employees with physical handicaps?                                                  Please Select Yes No

14.) Do employees travel out of state? (If "YES", please indicate state(s) of travel and frequency)  Please Select Yes No

15.) Are athletic teams sponsored?                                                                 Please Select Yes No

16.) Are physicals required after offers of employment are made?                          Please Select Yes No

17.) Any other insurance with this insurer?                                                        Please Select Yes No

18.) Any prior coverage declined / cancelled / non-renewed in the last three (3) years?  Please Select Yes No

19.) Are employee health plans provided?                                                                Please Select Yes No

20.) Do any employees perform work for other businesses or subsidiaries?                Please Select Yes No

21.) Do you lease employees to or from other employers?                                       Please Select Yes No

22.) Do any employees predominantly work at home? If "YES", # of employees.                Please Select Yes No

23.) Any tax liens or bankruptcy within the last five (5) years? (If "YES", please specify)      Please Select Yes No

24.) Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? (If YES", explain including entity name(s) and policy numbers(s).                                        Please Select Yes No