Insurance Force – Workers’ Compensation Quote

Name

Email

Company

Entity Type

Year Business Established

Federal ID Number

Requested Effective Date of WC Policy

Number of Employees

I Have Employees That Live and/or Work OUTSIDE of Maryland

Yes
No

Owners / Officers

Under Maryland law, (1) any officer of a close corporation whether incorporated in Maryland or elsewhere; (2) any member of an LLC; (3) any member of a P.A.; or (4) up to five officers of any other corporation, can elect to exclude themselves from Workers’ Compensation coverage. Sole Proprietors and Partners are automatically excluded and must elect to include themselves.

Name	Title	% of Ownership	Include (I) or Exclude (E)

Estimated Payroll

i.e. MD, Clerical, $120,000 // Common Job Class Descriptions: Clerical, Outside Sales, Driver, Service, Installation

State	Job Class Description	Annual Payroll

The Payroll Figures Above Include or Exclude Owners/Officers?

Yes, owner/officers' payroll is INCLUDED
No, owners/officers' payroll is EXCLUDED

Number of WC losses in last 3 years:

Approximate Dollar Amount of Losses Paid