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Convenience Store - Workers Compensation Form

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 Information

Company Name *

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

E-Mail Address *

Primary Phone Number *

Alternate Phone Number

Federal ID or SSN:

State Unemployment Number:

Breakdown of Ownership:

Are owners to be included or excluded?

Included
Excluded

Years in Business:

Years Experience:

Number of Employees:

Annual Employee Payroll

Do you currently have insurance?

Current Insurance Provider

Have you been cancelled/non-renewed?

Yes
No

If yes, list the reason:

Losses in past three years:

Is health insurance provided for employees?

Yes
No

Submission Validation

Required

Important Notice
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.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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Judy Carter & Associates 300 Vestavia Parkway Suite 1600 Birmingham, Alabama 35216