Please enable JavaScript in your browser to complete this form. - Step 1 of 3General Business InfoThe form below will give us the info we need to answer your questions about cost and options. Workers Comp requires a minimum of 2 full time employees not counting officers/owners.Full Time Employees *Part Time Employees *Annual Payroll *Annual Sales *Limits of Liability Desired$100,000$500,000$1,000,000Do you use subcontractors? *NoYesEstimated annual Insured sub-contractors costEstimated annual Uninsured sub-contractors Do you currently have insurance? *NoYesExpirationInsurance Company NameHave you had any claims? *NoYesProvide details of claim and amount paid by insurance companyIf you had losses we will require hard copy of losses from insurance company.Do you work outside the State of Florida? *NoYesHow many years managing experience on this type of business?< 1 Years1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years> 10 YearsDescription of services or products: *NextDuties / ClassificationsEnter by duties / classifications the number of employees that apply, fulltime, part-time and annual salariesDuties #1Full time #1012345678910> 10Part time #1012345678910> 10Salary #1Duties #2Full time #2012345678910> 10Part time #2012345678910> 10Salary #2Duties #3Full time #3012345678910> 10Part time #3012345678910> 10Salary #3Owners / Officers InformationEnter information about the company officers.How many owners? *Owner Name #1Salary #1% Owner #1Include #1Yes, IncludeNo, ExcludeOwner Name #2Salary #2% Owner #2Include #2Yes, IncludeNo, ExcludeOwner Name #3Salary #3% Owner #3Include #3Yes, IncludeNo, ExcludePreviousNextCompany Name *Sole proprietor, corporation or LLC name Contact Name *Mailing Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs there a different physical address? *NoYesPhysical Address (if different than mailing address)Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Mobile PhoneTxt Msg ConsentYesNoBy select YES and entering your telephone number, you expressly authorize Dopazo & Associates, Inc. (“Dopazo”) to call or text you with offers and reminders at the number you provided, including through the use of the possible use of automated technology and recorded messages. You certify that the number you provided is your own number. If you change your number, you will notify Dopazo as soon as possible. You are not obligated to provide this authorization and it is not a condition to receive a quote or purchase or renew your insurance. You may revoke this authorization at any time by remove@dopazo.com. You understand and agree that standard text messaging rates will apply to any text messages sent to you by Dopazo and that Dopazo will not be responsible for any charges for text messaging.Federal Employer Number FEIN *Website / URLAcknowledgement *I AgreeI acknowledge and understand that insurance coverage cannot be bound or changed via submission of any online form/application provided on this site or otherwise. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed in writing directly by a licensed agent.Submit