Big E Vendors: Workers’ Compensation
Request for Quote

General Information

Primary contact name*

Phone

Email*

Requested effective date

Name of employer
(Name the sole proprietor, general partner(s) or trustee(s) along with the trade name of the business)

Federal Employer Identification Number (Do NOT provide a social security number)

If Federal Employer Identification Number is pending, attach a copy of IRS application
Yes Pending
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Upload IRS application

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City

State
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Legal status

—Please choose an option—Sole ProprietorLLCPartnershipLLPCorporationTrustLimited PartnershipOther
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If “Other,” please specify

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Does the employer have any outstanding audits or inspections on a prior workers’ compensation policy?
—Please choose an option—YesNo

Corporate Officers, Sole Proprietors, Partners and Members

If there are more than four officers, partners or members, attach a list including information for each additional individual.

For sole proprietors, partners, LLC members and LLP partners: list the names, titles, ownership and duties of all proprietors, partners or members. Enter “ELECT” to indicate whether each is electing coverage; otherwise enter “EXEMPT.” Sole proprietors, partners, and members are not covered unless they elect coverage.

For corporations: list the name, title, ownership duties and actual salary of all officers listed in the Corporate Articles of Organization. Enter “EXEMPT” to indicate whether each has chosen to waive coverage in accordance with MA Regulation 452 CMR 8.06; otherwise select “ELECT.”

Member/Officer 1

• Name
  

• Title
  

• % Ownership
  

• Elect/Exempt
  —Please choose an option—ElectExempt

• Duties
  

• Salary
  

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Member/Officer 2

• Name
  

• Title
  

• % Ownership
  

• Elect/Exempt
  —Please choose an option—ElectExempt

• Duties
  

• Salary
  

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[group officer3]

Member/Officer 3

• Name
  

• Title
  

• % Ownership
  

• Elect/Exempt
  —Please choose an option—ElectExempt

• Duties
  

• Salary
  

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[group officer4]

Member/Officer 4

• Name
  

• Title
  

• % Ownership
  

• Elect/Exempt
  —Please choose an option—ElectExempt

• Duties
  

• Salary
  

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Upload additional names

Business of Employer