Workers’ Compensation Insurance Program
Featuring Pay-As-You-Go and Monthly Billing Options

Fill in as much information as you can. Anything you are not sure of please use the recommended option or leave it blank.
Applicant Name *  
DBA
FEIN or SSN
 or 
Legal Entity
Address *  
City *  
State *  
Zip *
(12345)  
Proposed Effective Date *
Years In Business *  
Number of Employees
Estimated Annual Payroll
Number of Losses
Description of Operations  *  
Previous coverage:


APPLICANT CONTACT INFORMATION

Please enter the contact information of the person InsureLinx should contact.
Contact *  
Contact Phone *
 Ext:    
Contact Fax
 Ext:    
 
Email *
Payroll Rep Email