To apply for a workers’ compensation quote with CompSource Oklahoma, please provide the following information, then click the “send form” 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. *denotes a required field. *Do you have business operations in any state(s) other than Oklahoma?   Yes No *Do you hire employees in any other state other than Oklahoma?   Yes No *Business Name: *Mailing Address: County: Adair Alfalfa Atoka Beaver Beckham Blaine Bryan Caddo Canadian Carter Cherokee Choctaw Cimarron Cleveland Coal Comanche Cotton Craig Creek Custer Delaware Dewey Ellis Garfield Garvin Grady Grant Greer Harmon Harper Haskell Hughes Jackson Jefferson Johnston Kay KingfisherKiowa Latimer Leflore Lincoln Logan Love McClain McCurtain McIntosh Major Marhsall Mayes Murray Muskogee Noble Nowata Okfuskee Oklahoma Okmulgee Osage Ottawa Pawnee Payne Pittsburg Pontotoc Pottawatomie Pushmataha Roger Mills Rogers Seminole Sequoyah Stephens Texas Tillman Tulsa Wagoner Washington Washita Woods Woodward Out of State *City:    *State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY    *Zip: *Telephone Number: Street Address or Directions to Location: *Type of Business: Sole Proprietor Partnership Corporation Other If type of business is Sole Proprietor and you do not have a Federal Tax ID Number, you are requested to provide your Social Security Number. *Do you have a Federal Tax ID Number?   No Yes *Federal Tax Id or SSN: *Are you currently in the process of liquidation or termination of this business?   No Yes    If yes, please explain: *Have you ever filed bankruptcy or is the business currently in bankruptcy?   No Yes    If yes, please explain: Contact Person:    Phone: Audit Address: County: Adair Alfalfa Atoka Beaver Beckham Blaine Bryan Caddo Canadian Carter Cherokee Choctaw Cimarron Cleveland Coal Comanche Cotton Craig Creek Custer Delaware Dewey Ellis Garfield Garvin Grady Grant Greer Harmon Harper Haskell Hughes Jackson Jefferson Johnston Kay KingfisherKiowa Latimer Leflore Lincoln Logan Love McClain McCurtain McIntosh Major Marhsall Mayes Murray Muskogee Noble Nowata Okfuskee Oklahoma Okmulgee Osage Ottawa Pawnee Payne Pittsburg Pontotoc Pottawatomie Pushmataha Roger Mills Rogers Seminole Sequoyah Stephens Texas Tillman Tulsa Wagoner Washington Washita Woods Woodward Out of State City:    State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY    Zip: *Have you had previous Workers’ Compensation coverage?   No Yes       If no, skip to next section.       If yes, please complete all information in this section. Carrier Name: Policy Number: Date Cancelled or Expired:   Anniversary Date: State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OKOR PA PR RI SC SD TN TX UT VA VT WA WI WV WY If appplicable:          Experience Modifier:   Modification Effective Date:   Rating ID Number: Carrier Information For the Previous Three (3) Years:      (type "none" if not applicable) Carrier:      Policy Number:      Period: Carrier:      Policy Number:      Period: Carrier:      Policy Number:      Period: Have you ever been cancelled for non-payment? No Yes Have you ever been cancelled for any other reasons? No Yes    If yes, please explain: *Do you have a current policy in another state that extends coverage to residents of other states who are temporarily working in Oklahoma?   No Yes    (Coverage for employees hired in state(s) other than Oklahoma cannot be provided    under the CompSource Oklahoma policy.) *Job description of all work performed: *Total number of employees in Oklahoma excluding owners/officers: (can be zero) *Estimated annual payroll for all employees excluding owners/officers: (can be zero) *Do you now or do you intend to hire family members related by blood or marriage?   No Yes     If yes, were the payrolls for family members included in the gross payroll and were family members included in the total number of employees?   No Yes *Do you use privately owned or leased aircraft? No Yes     If yes, how many seats excluding pilot? *Do you intend to engage in the business of leasing or otherwise providing your employees to work for other businesses? No Yes     If yes, please explain: *Do you use or intend to use workers in your business/operation who are leased or provided by a temporary employment service? No Yes *Do you use or intend to use subcontractors?   No Yes     If yes, are they insured for workers comp?   Yes No *Do you engage or intend to engage in any farm operations?   No Yes *Do you employ any in-servants or domestic workers?   No Yes     (maid, chauffeur, groundskeeper, etc.) *Are you related to or associated with anyone in this business who has been denied coverage or is not in good standing with CompSource Oklahoma (formerly the Oklahoma State Insurance Fund)?   No Yes     If yes, please name:   Title First Name MI Last Name SSN Active in business? Coverage desired? 1. President Vice President Secretary Treasurer Sec-Treas. Sole Proprietor Partner Other   No Yes   No Yes 2. President Vice President Secretary Treasurer Sec-Treas. Sole Proprietor Partner Other   No Yes   No Yes 3. President Vice President Secretary Treasurer Sec-Treas. Sole Proprietor Partner Other   No Yes   No Yes 4. President Vice President Secretary Treasurer Sec-Treas. Sole Proprietor Partner Other   No Yes   No Yes 5. President Vice President Secretary Treasurer Sec-Treas. Sole Proprietor Partner Other   No Yes   No Yes 6. President Vice President Secretary Treasurer Sec-Treas. Sole Proprietor Partner Other   No Yes   No Yes *Are any other businesses owned by any of the above persons?   No Yes       If no, skip to next section. If yes, answer the following questions: Business Names: Owners Names and Ownership Percentages: Operations in Oklahoma? No Yes Number of Oklahoma Employees: Does this business have current workers’ comp coverage? No Yes    If yes, who is the current carrier?      Policy Number:    Dates of coverage: *Your Name: *Your Phone Number: Your E-mail Address: Your Fax Number: Relation to Applicant:   self accountant agent other Are you a Contracted Agent with CompSource Oklahoma?   No Yes Please click only once to avoid transaction duplication.     back to top