Workers Compensation Quote

Date of Birth (needed to start your quote) *

Business Name (not required)

Type of Business *

Limited Liability Company (LLC) Corporation (C Corp or S Corp) Sole Proprietorship Partnership (General or Limited)

Is there another owner? (not required)

Yes No

Owner's Payroll Annually (not required)

W-2 Employee Payroll Annually (not required)

Owner-Only / Ghost Policy? (no employees — a certificate to satisfy contract requirements) *

Yes — owner only, no employees No — I have employees

Do you hire Subcontractors (1099) *

Yes No

1099 Subcontractor Payments Annually (not required)

Travel Out of State for Work? (not required)

Yes No

States you work in besides Oklahoma? (not required)

Do you have coverage for this now? *

Yes No

Who is it with now? (not required)

When does that policy expire? (not required)

Description of Work Performed *

Is this a trucking / hauling business? (not required)

Yes No

1. What do you transport/haul? Please be as specific as possible. (not required)

1a. What percentage of your time do you spend transporting/hauling each item? (not required)

2. Number of owner/operators you use (not required)

2a. Number of team drivers (not required)

3. Do you have employees who are residents of states other than Oklahoma? (not required)

Yes No

List the states and the number of drivers who reside in each (not required)

4. What is the radius of operations? (not required)

4a. Percentage of time spent LESS than 200 miles from your primary business location (%) (not required)

4b. Percentage of time spent MORE than 200 miles away from your primary business location (%) (not required)

4c. Do you have a terminal located in Oklahoma? (not required)

Yes No

Where is the Oklahoma terminal? (not required)

4d. With no terminal in Oklahoma, where are your Oklahoma-hired drivers dispatched from? (not required)

4e. With no terminal in Oklahoma, where do the drivers pick up their loads? (not required)

5. Which states do the drivers travel through? List each state and the percentage of time in each. (not required)

6. Do you own the goods you haul, or are you hauling goods that belong to others? (not required)

We own the goods Goods belong to others Both

7. What percentage of your time do you spend hauling waste fluids from oil well sites for disposal? (%) (not required)

8. List any hazardous materials you haul (write "None" if none) (not required)

9. Describe your hiring process (not required)

9a. Do you require pre-employment physicals? (not required)

Yes No

9b. Do you require pre-employment background checks? (not required)

Yes No

10. Are all drivers hired/contracted within the state they live? (not required)

Yes No

If no, please explain (not required)

11. Describe your safety program (not required)

12. Are you contracted to haul for another company? (not required)

Yes No

13. Do you need cargo insurance (Motor Truck Cargo)? (not required)

Yes No

How much cargo coverage? (not required)

Other cargo amount $ (not required)

Cargo deductible you prefer (not required)

What do you haul? (not required)

Most valuable load you carry at one time $ (not required)

Do you haul refrigerated (reefer) loads? (not required)

Yes No

Does your business do any roofing work? (not required)

Yes — commercial roofing (some or all) Yes — residential roofing only No

How many years has the business been doing roofing? (not required)

Payroll by job type (not required)

Annual payroll and how many people do each job. Leave a row blank if nobody does it.

	Annual payroll $	Full-time	Part-time
Roofing labor (5551)	Roofing labor (5551): annual payroll $	Roofing labor (5551): full-time employees	Roofing labor (5551): part-time employees
Executive supervisors (5606)	Executive supervisors (5606): annual payroll $	Executive supervisors (5606): full-time employees	Executive supervisors (5606): part-time employees
Outside salespeople (8742)	Outside salespeople (8742): annual payroll $	Outside salespeople (8742): full-time employees	Outside salespeople (8742): part-time employees
Clerical office (8810)	Clerical office (8810): annual payroll $	Clerical office (8810): full-time employees	Clerical office (8810): part-time employees

Do you do any of the following? (check all that apply) (not required)

What percentage of your work is done by subcontractors? (%) (not required)

What work do the subcontractors do? (not required)

Employee turnover in the last 12 months (%) (not required)

Experience mod, if you have one (and its effective date) (not required)

Do you do substance abuse testing when hiring? (not required)

Yes No

Do you hire from union halls? (not required)

Yes No

Do you use leased employees? (not required)

Yes No

Do you use day laborers? (not required)

Yes No

Do you provide health insurance to your employees? (not required)

Yes No

Do you have a return-to-work program? (not required)

Yes No

Do you have a written safety program? (not required)

Yes No

Do you hold safety meetings for employees? (not required)

Yes No

Is a foreman part of each working crew? (not required)

Yes No

Do you provide training to your employees? (not required)

Yes No

Are employees required to wear personal protective equipment? (not required)

Yes No

Do you have a hazardous materials communication program? (not required)

Yes No

Do you have an equipment inspection and maintenance program? (not required)

Yes No

Do employees drive company vehicles? (not required)

Yes No

Do you work on OCIP or wrap-up projects? If yes, what % of your work? (not required)

Which of these roofing methods do you use? (check all that apply) (not required)

Do you have designated hot tar employees? (not required)

Yes No

Is a fire watch provided on hot tar or torch jobs? (not required)

Yes No

Are fire extinguishers or other fire suppression equipment on site during hot tar or torch work? (not required)

Yes No

Do you inspect the roof before work starts to find strong and weak areas? (not required)

Yes No

How are materials delivered to the roof? (conveyor or boom truck, hoist, crane, carried up ladders, etc.) (not required)

Steepest roof pitch you work on (for example 8/12) (not required)

Highest you work off the ground (feet) (not required)

Are ladders tied off? (not required)

Yes No

What fall protection do you use? (check all that apply) (not required)

Other fall protection (not required)

How much of your work is residential, commercial and industrial? (not required)

Total should equal 100%

	% of work	Total
Residential	Residential (% of work)	0%
Commercial	Commercial (% of work)	0%
Industrial	Industrial (% of work)	0%
Subtotals	0%	0%

How much of your work is new construction, remodeling and service or repair? (not required)

Total should equal 100%

	% of work	Total
New construction	New construction (% of work)	0%
Remodeling	Remodeling (% of work)	0%
Service / repair	Service / repair (% of work)	0%
Subtotals	0%	0%

Heaviest thing employees lift by hand (lbs) (not required)

Do you have more than one business location? (not required)

Yes No

Has your business had work comp coverage? (not required)

Yes No

Years in Business (not required)

Years of experience (not required)

When does your insurance expire? (not required)

Claims in the Last 3 Years? *

Yes No

When do you want your policy to start? *

Do you have anything else you want to let us know? (not required)

How would you like us to contact you? (not required)

Upload a copy of the completed and signed contract/agreement (not required)

Up to 5 files total, 10 MB each — PDF, photos, or documents.

Upload your old policy & 4-5 Year Loss Run Report & Experience Mod Report. (not required)

Up to 5 files total, 10 MB each — PDF, photos, or documents.

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