Business Information

Tell us about the business applying for Workers' Compensation coverage.

Company Details

Business Name *

Organizational Structure *

Year of Formation *

Federal Employer Identification Number (FEIN) * 9-digit number issued by the IRS

NAICS Code * 6-digit industry classification code

biBerk Industry Code

Company Website

Years of Management Experience *

Mailing Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Contact Information

Provide the primary contact details for this application.

Primary Contact

Full Name *

Email Address *

Phone Number *

Policy Details

Specify coverage information for this Workers' Compensation policy.

Coverage Information

Policy Effective Date *

Coverage Type

Locations & Employees

Add each business location and the employees at each site.

Location 1 — Primary

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Employee Classifications

Classification 1

Job Code *

Total Annual Payroll *

Full-Time Employees *

Part-Time Employees

Claims History

Provide information about any prior Workers' Compensation claims.

Prior Claims

Does the organization have any prior Workers' Compensation claims? *

Yes

No

Additional Interests

Review & Submit

Please review your application details before submitting for a quote.

Underwriting Notice and Documentation Requirement

You may be required to submit proof of insurance claims history, also called loss runs, for up to the last 3 years. If we request it after you buy then it would be due by 30 days from the policy start date.

I acknowledge and agree to the above terms *