Request a Quote

To apply for a workers’ compensation quote with CompSource Oklahoma, please provide the following information, then click the “Submit” button. An Underwriter will contact you for additional information if needed, provide you with a premium quote, and mail an application for coverage if desired.

Is this a temporary staffing or employee leasing entity?

yes no

Do you have operations outside the state of Oklahoma?

yes no

Total Annual Payroll

Basic Business Information

Business Name

Describe your business operations.

Mailing Address

County

City

State

Zip

Telephone

Format: xxx-xxx-xxxx

Enter with dashes; example: 405-555-5555

Street Address or Directions to Location

Type of Business

Do you have a Federal Tax ID number?

yes no

Federal Tax ID or SSN

Audit Information

Contact Person: First Name

Contact Person: Middle Name

Contact Person: Last Name

Phone

Format: xxx-xxx-xxxx

Enter with dashes; example: 405-555-5555

Audit Address

County

City

State

Zip

Workers' Compensation Supplemental

Does applicant own, operate, or lease aircraft/watercraft?

yes no

Explain:

Do/Have past, present, or discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc)

yes no

Explain:

Any work performed underground or above 15 feet?

yes no

Explain:

Any work performed on barges, vessels, docks, bridge over water?

yes no

Explain:

Is there any volunteer or donated labor?

yes no

Explain:

Any other insurance with this insurer?

yes no

Explain:

Any prior coverage declined/canceled/non-renewed (last 3 years)? Not Applicable in MO.

yes no

Explain:

Do any employees perform work for other businesses or subsidiaries?

yes no

Explain:

Do you lease employees to or from other employers?

yes no

Explain:

Any tax liens or bankruptcy within the last 5 years?

yes no

Explain:

Any undisputed and unpaid workers' compensation premium due from you or any commonly managed or owned enterprises?

yes no

Explain:

Owners/Officers Information

Title

First Name

Middle Initial

Last Name

Social Security Number

Active in Business

yes no

Coverage Desired

yes no

Add Owner/Officer

Additional Locations

Additional Location 1

Mailing Address

County

City

State

Zip

Telephone

Location Name

Additional Location 2

Mailing Address

County

City

State

Zip

Telephone

Location Name

Additional Location 3

Mailing Address

County

City

State

Zip

Telephone

Location Name

Add Additional Location

Contact Information

Your Name

First Name

Middle Name

Last Name

Your Phone Number

Your Email Address

Your Fax Number

Relationship to Applicant

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