New Workers' Comp Submission

Draft

Business Details

Enter the applicant's business information.

Primary Contact

Who should we contact regarding this submission?

Contact Details

Full Name *

Email *

Phone *

Policy & Program

Configure the requested policy term and tell us about current coverage.

Policy Term

Requested Effective Date *

Requested Expiration Date

Program

Current Coverage

Current Carrier

Current Policy Number

Expiring Annual Premium

Has any coverage been declined, cancelled, or non-renewed in the past 3 years? *

Yes

Program Eligibility

Confirm the risk fits the hospitality program's underwriting appetite.

Operations Profile

Restaurant Classification *

Maximum Occupancy *

States in Which Employees Work *

Number of Volunteers

Experience Modification Factor Leave blank if not experience rated — your underwriter will confirm.

Percentage of Work Subcontracted Percent of operations performed by subcontractors

Officers, Locations & Losses

List officers and owners with their coverage elections, add each business location, and report any prior claims.

ⓘ Officer inclusion elections are governed by state rules. Excluded officers' payroll is not used in premium calculation.

Officer 1

Officer / Owner Name *

Official Title *

Ownership Percentage *

Annual Payroll *

WC Job Code

Coverage Election *

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 *

Annual Revenue at This Location

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

Review & Submit

Verify all information before submitting your application.

⚠

Delegated Authority Notice
This quote will be issued by Meridian Specialty Underwriters under delegated underwriting authority from Granite Peak National Insurance Company. Coverage is subject to receipt of loss runs for the past 3 years within 30 days of binding.

I acknowledge the delegated authority notice and documentation requirements above. *