Dimirak Financial Corp

Workers' Comp Quote Request

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Agency: Dimirak Financial Corp

Effective Date

Coverage

Company Name(if applicable)

State

Business Entity

FEIN/SSN

FEIN SSN

It appears that you have an existing Application or Policy!

Number of Employees (not including owners)

Number of Owners

Do you hire subcontractors (1099s) or use day labor?

Yes No

Owner 1

First Name

Last Name

Phone Number

Type of Work

Does the owner wish to be included?

Yes No

Owner Payroll

Add an accident policy for $0.00

Yes View Accident Policy Benefits

Date of Birth

Employers Liability Limits

Description of Operations

Warning!

By checking “No”, I have verified that the company does not use, or plan to hire, subcontractors (1099ers) or day labor during the policy period. If they do, I have informed them that they must notify me as their agent and SolePro within 24 hours.

Warning!

By checking “No”, I have verified that the company does not use, or plan to hire, subcontractors (1099ers) or day labor during the policy period. If they do, You must notify your agent and SolePro within 24 hours.

Eligibility Change

The owner/s must be included for the Solo I program. Please apply for Solo X if you wish to exclude owners for workers’ comp coverage.

Eligibility Change

The owner/s must be excluded for the Solo X program. Please apply for Solo I if you wish to include owners for workers’ comp coverage.

Eligibility Change

The insured must have zero employees to be eligible for Solo I. Please apply to Plus.

Eligibility Change

The insured must have employees to be eligible for Plus. Please apply to Solo X (owner is excluded) or Solo I (owner is included).

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Existing Quote

This insured already has an quote started for Program. Open app?

Open

Existing Application

This insured already has an application started for Program. Open app?

Open

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