Insurance Agents — Submit a Workers' Comp Prospect

Prospect Submission

Fields marked * are required. Complete submissions with an ACORD application are prioritized.

1 Agent Contact Information

Agent Name*

Agency Name*

Agent Email*

Agent Phone*

FL Agent License # (optional)

Agency City, State (optional)

Requested Commission (%) (optional)

2 Prospect Details

Business Legal Name*

DBA (optional)

Contact Name*

FEIN (optional)

Contact Phone (optional)

Contact Email (optional)

Business Address*

City*

County (optional)

ZIP*

3 Operations & Coverage

Industry*

NCCI Class Code(s) (optional)

Years in Business (optional)

Number of Employees*

Estimated Annual Payroll*

Experience Mod (X-Mod) (optional)

Current Carrier (optional)

Current Annual Premium (optional)

Desired Effective Date*

Claims in Past 3 Years (optional)

Description of Operations / Notes (optional)

4 ACORD Application

Attach the completed ACORD 130 (Workers' Compensation Application). PDF, Word, or image files accepted. Combined attachments must be under 8 MB.

ACORD Application*

Drop file or click to upload

PDF, DOC, DOCX, JPG, PNG, TIFF

Loss Runs / Supplemental Docs (optional)

Drop file or click to upload

PDF, DOC, XLS, JPG, PNG

🔒 Submissions are sent securely and used only to prepare quotes for your client.