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Workers compensation Construction industry


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Name
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First Name
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Last Name
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Company Website
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
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Nature of Business
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Number of Full time employees
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Number of Part Time Employees
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Does the company work outside of Florida?
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How many years of construction experience does the owner have?
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Is this the owners first construction company? If no, list the others.
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What other construction companies has the owner worked for in the past?
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Has this company, or any other companies that you have been affiliated with, ever received a stop work order from the state Division of Workers Compensation?
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Does the company have a business checking account?
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Describe the typical type of work/job this company performs.
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What construction/business license(s) do the owners/officers currently hold or plan to obtain in the next 12 months?
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How many employees will be performing and/or supervising construction work?
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What is the average hourly wage the company pays its (hourly) workers?
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Does/will the company pay employees (full time, part time, or day laborers) partially or wholly in cash?
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How much payroll do you estimate the company will have in the next 12 months?
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How many support staff employees does the company have who are in sales and/or clerical only positions?
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Does the company file or plan to file a Florida Employer's Quarterly Report (RT-6 unemployment tax return) on all employees? If no, why?
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If the company uses subcontractors, does the company verify that all subcontractors have either a valid exemption from workers compensation or are covered by a worker's compensation policy?
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How much do you estimate the company will have in subcontractor labor costs this year?
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Describe the type of work that the company typically subcontracts.
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What percentage of the company's work is residential?
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What percentage of the company's work is Commercial?
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What percentage of the company's work would be classified as a General Contractor?
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What percentage of the company's work would be classified as a subcontractor?
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What percentage of the company's work is
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What percentage of the work is from answers to the previous question?
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How many stories above ground does your company work?
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What type of vehicle is used in the course of the company's work?
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What is the longest distance you and the company's employees typically drive to jobsites?
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How many employees do you transport to jobsites?
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Does the company retain all job files?
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Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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