AmTrust Financial — Workers' Compensation Application

Business Details

Enter the applicant's business information.

Primary Contact

Who should we contact regarding this application?

Contact Details

Full Name *

Email *

Phone *

Policy & Coverage

Configure the requested coverage details.

Policy Configuration

Requested Effective Date *

Line of Business

Business Locations

Add all business locations and employee classifications at each.

ⓘ Enter at least one location. The first location is automatically designated as primary. Add employee job classifications under each location to calculate your premium estimate.

Location 1Primary

Street Address *

Address Line 2

City *

State *

ZIP *

Employee Classifications

Classification 1

WC Job Code *

Annual Payroll *

Full-Time Employees *

Part-Time Employees

Loss History

Report any Workers' Compensation claims from the past 3 years.

Prior Claims

Has the applicant had any Workers' Compensation claims? *

Yes

No

Additional Interests

Review & Submit

Verify all information before submitting your application.

⚠

Underwriting Notice
You may be required to submit proof of insurance claims history (loss runs) for up to the last 3 years. If requested after purchase, documentation is due within 30 days of the policy start date.

I acknowledge the underwriting notice and documentation requirements above. *

New Workers' Comp Application

Business Details

Primary Contact

Policy & Coverage

Business Locations

Loss History

Review & Submit