Section 1 - General Information. Section 2 - Current Insurance Program

Section 1 - General Information

Company name and entity type: Contact name, email address,

and phone number: Mailing address: Website: SIC Code & Description of Operations (including how company generates revenue): Federal Tax ID: Annual revenue: Year founded:

Section 2 - Current Insurance Program

Have prior insurance: Yes No

If current coverage is in force, please answer the following questions or attach copies of the Declaration Pages from each of your policies.

Policy type(s): Name of carrier(s): Renewal date(s):

Description of any prior claims in past 5 years:

For Property / General Liability, complete all sections except Section 3. For Directors & Officers Liability, Employment Practices Liability, or E&O/Cyber Liability,

please email [email protected] for the correct application.

Section 3 - Workers Comp*

* See page 5 for state regulations which govern when WC is required.

To obtain an accurate quote, please fill in the table below – if you have a spreadsheet that outlines these details, please attach.

Note – Workers Comp premium is driven by two factors: the rate associated with the employee class code (based on the employee’s job duties) and the total payroll issued during the policy term. Companies may have more than one class code, so please provide

detailed descriptions of job duties.

Location Address Job Title / Class Code

ex: Engineer, Sales, etc. Number of Employees Annual payroll

Fill in the table below for any employees who work from home.

Home Address Job Description /

Class Code Annual Payroll

Do you have outside investors? Yes No

If no*, would you like to exclude owners/officers from Workers Compensation Benefits? *Note – companies with outside investors must include the owners’ payroll on Workers Compensation policy

Yes No

Ownership breakdown: (We must account for 100% Ownership. Please note

that some carriers will require full names and ownership percentages prior to binding)

Section 4 - General Liability

Select one based on contract requirements.

$1,000,000 per occurrence / $2,000,000 general aggregate

$2,000,000 per occurrence / $4,000,000 general aggregate

Section 5 - Umbrella Liability

Desired limit (if higher limits are required):

Section 6 - Property

Business Personal Property (BPP)

Includes your furniture, fixtures, and inventory – excluding antiques, collections, and other fine arts. BPP limit at location #1:

BPP limit at location #2:

Business Personal Property (BPP)

Includes your furniture, fixtures, and inventory – excluding antiques, collections, and other fine arts. Computers limit at location #1:

Section 7 - Location Information (required for each location)

Frame Non Combustible Fire Resistive Joisted Masonry Masonry Non Combustible

If the building that you occupy is owned by your organization, or you are required to provide building coverage, what is the replacement cost of the building?

Office has sprinkler system: Yes No Office has alarm system: Yes No If the building is over 30 years old, provide approximate year updated for each of the below.

Year Updated, Roof: Year Updated, Heating / ventilation: Year Updated, Plumbing: Year, Updated, Electric:

Workers Compensation State by State Requirements

Every state has its own minimum requirements regarding when a company must purchase Workers Comp. Different rules apply in each state, and unique rules may apply to domestic workers and certain industries such as agriculture and construction. This list is only to be used as a general guide, and Zenefits encourages you to visit your state’s Workers Comp website for the most current guidelines. A link to all 50 states Workers Comp websites can be found here.

State Employee count at which WC is typically required State Workers Compensation Website Arkansas 3 http://www.awcc.state.ar.us/ Florida 4 Mississippi 5 Missouri 5 New Mexico 3 North Carolina 3 South Carolina 4 Tennessee 5

Texas Optional for most

companies

Virginia 3

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Call 1(888) 249-3263

or email [email protected]