app.pogo.co Open in urlscan Pro
209.10.86.16 Public Scan

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URL:
https://app.pogo.co/application/status?UniqueKey=487f60b9-d4c3-4290-a91a-9058980ed7ae
Submission: On November 20 via manual (November 20th 2024, 6:51:35 am UTC) from IN — Scanned from US

Form analysis
4 forms found in the DOM

POST /Application/SaveAppPartialData

<form action="/Application/SaveAppPartialData" method="post">
  <div class="modal-header">
    <div class="modal-title overviewTitle">Edit Info</div>
    <button type="button" class="close" data-dismiss="modal" aria-label="Close">
      <span aria-hidden="true">×</span>
    </button>
  </div>
  <div class="modal-body">
    <input type="hidden" id="PartialAppUpdateAppId" name="appId" value="3557">
    <input type="hidden" id="PartialAppUpdateproposalId" name="proposalId" value="">
    <input type="hidden" id="PartialAppUpdateansId" name="ansId" value="">
    <div class="row dataEntry" id="WC_withlimit_Block">
      <div class="col-md-5 col-lg-5 col-sm-12 col-xs-12">
        <label class="registerLabel"> Employer Liability Limits: </label>
      </div>
      <div class="col-md-7 col-lg-7 col-sm-12 col-xs-12">
        <div class="input-group">
          <select class="form-control  registerfield" id="CurrentApp_LiabilityLimitID" name="CurrentApp.LiabilityLimitID">
            <option value="-1">Employer Liability Limits</option>
            <option value="1">$100,000/$500,000/$100,000</option>
            <option selected="selected" value="2">$500,000/$500,000/$500,000</option>
            <option value="3">$1,000,000/$1,000,000/$1,000,000</option>
            <option value="4">$500,000/$1,000,000</option>
            <option value="5">$1,000,000/$2,000,000</option>
            <option value="6">$2,000,000/$4,000,000</option>
          </select>
          <span class="field-validation-valid text-danger" data-valmsg-for="CurrentApp.LiabilityLimitID" data-valmsg-replace="true"></span>
        </div>
      </div>
    </div>
    <div id="WC_otherlimit_Block" style="display:none;"></div>
    <div class="row dataEntry">
      <div class="col-md-5 col-lg-5 col-sm-12 col-xs-12">
        <label class="registerLabel">Effective Date: </label>
      </div>
      <div class="col-md-7 col-lg-7 col-sm-12 col-xs-12">
        <div class="input-group">
          <input class="form-control futuredatepicker registerfield" id="formattedEffectiveDate" name="formattedEffectiveDate" type="text" value="11/18/2024">
          <span class="field-validation-valid text-danger" data-valmsg-for="formattedEffectiveDate" data-valmsg-replace="true"></span>
        </div>
      </div>
    </div>
  </div>
  <div class="modal-footer">
    <div class="btn-group" role="group" aria-label="...">
      <button type="submit" class="btn btn-primary">Update</button>
    </div>
  </div>
</form>

POST /Application/SaveEditAppCoverageData

<form action="/Application/SaveEditAppCoverageData" class="form-horizontal" enctype="multipart/form-data" method="post">
  <div class="modal-header">
    <div class="modal-title overviewTitle" id="filterModalLabel">Edit details</div>
    <button type="button" class="close" data-dismiss="modal" aria-label="Close">
      <span aria-hidden="true">×</span>
    </button>
  </div>
  <div class="modal-body">
  </div>
  <div class="modal-footer">
    <button type="submit" id="btnSaveCovDetails" class="btn btn-success ">Update</button>
  </div>
</form>

POST /Application/Bind

<form action="/Application/Bind" enctype="multipart/form-data" method="post"> <input type="hidden" id="BindAppObkey" name="BindAppObkey" value="">
  <div class="row" style="margin-bottom:20px;">
    <div class="col-md-12">
      <input type="radio" name="typeOfBindPolicyAction" id="typeOfBindPolicyAction1" value="0" checked="checked" onclick="fnhandleBindPolicyPopup(this);"> <strong>Change Status Only?</strong> <small>&nbsp;&nbsp; (Use this option to change status
        without uploading policy)</small> <br>
      <input type="radio" name="typeOfBindPolicyAction" id="typeOfBindPolicyAction2" value="1" onclick="fnhandleBindPolicyPopup(this);"> <strong>Bind Policy?</strong>
    </div>
  </div>
  <div id="bindpolicy-changestatus-block" class="row">
    <div class="col-md-12 text-right">
      <div class="btn-group" role="group" aria-label="...">
        <button type="submit" id="btnchangestatuspolicy" class="btn btn-success ">Change Status</button>
      </div>
    </div>
  </div>
  <div id="bindpolicy-block" style="display:none;">
    <div class="row">
      <div class="col-md-4">
        <label>Type of Document:</label>
        <select class="form-control bindType" name="bindType" id="ddlBindType">
          <option value="1">Binder</option>
          <option value="2">Policy</option>
        </select>
      </div>
      <div class="col-md-8">
        <label>Policy Number:</label>
        <input type="text" id="PolicyNumber" name="PolicyNumber" style="width:100%;" class="form-control" placeholder="Policy Number">
        <div id="policynumbervalidation" style="display:none;" class="text-danger">Policy Number is required</div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-4">
        <label style="margin-top:10px;">Quote Offers:</label>
        <select id="BindProposalId" name="BindProposalId" class="form-control ">
          <option data-cr="1018" data-pr="1075.00" value="1632" selected="selected">Workers' Compensation - SolePro - $1075.00</option>
          <option data-cr="" data-pr="0.00" value="-1">Manual Quote Offer</option>
        </select>
        <div id="BindProposalIdValidation" style="display:none;" class="text-danger">Quote Offers selection is required</div>
      </div>
      <div class="col-md-4">
        <label style="margin-top:10px;"> Carrier:</label>
        <select class="form-control " id="bind-CarrierID" name="CarrierID" readonly="readonly">
          <option value="">Select</option>
          <option value="1">Accident Fund</option>
          <option value="1008">Amerisafe</option>
          <option value="1009">Amtrust</option>
          <option value="2">Benchmark</option>
          <option value="1015">biBerk</option>
          <option value="1013">Builders Mutual</option>
          <option value="7">Chubb</option>
          <option value="1005">Combined</option>
          <option value="1010">CompWest</option>
          <option value="1017">Cowbell</option>
          <option value="1014">Employers</option>
          <option value="1012">FastComp</option>
          <option value="1021">Frank Winston Crum</option>
          <option value="1016">Hartford</option>
          <option value="8">Liberty Mutual</option>
          <option value="4">Markel</option>
          <option value="1022">MEMIC</option>
          <option value="1019">Next</option>
          <option value="1020">Novatae</option>
          <option value="1011">Pie</option>
          <option value="1006">Sirius America</option>
          <option selected="selected" value="1018">SolePro</option>
        </select>
        <div id="bind-carrierValidation" style="display:none;" class="text-danger">Carrier is required</div>
      </div>
      <div class="col-md-4">
        <label style="margin-top:10px;"> Premium:</label>
        <div class="input-group ">
          <span class="input-group-addon " style="">$</span>
          <input type="text" class="form-control money " id="bind-PremiumAmount" name="PremiumAmount" placeholder="Enter Premium Amount" value="1075.00" readonly="readonly" im-insert="true" style="text-align: right;">
        </div>
        <div id="bind-premiumValidation" style="display:none;" class="text-danger">Premium required</div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div class="input-group">
          <label class="input-group-btn">
            <span class="btn btn-primary noleft">
              <input type="file" style="display: none;" name="file" id="inputGroupFile01"> Select File </span>
          </label>
          <input type="text" id="filename" class="form-control modalfield" readonly="" placeholder="Upload Doc / Binder">
        </div>
        <div id="bindervalidation" style="display:none;" class="text-danger">Binder Document Required</div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <label id="bind_dvLabelEmailNotification">Email Notification Message:</label>
        <label class="pull-right">
          <input type="checkbox" name="IsSendEmail" value="true" checked="checked" onclick="fnShowHideDocsEmailNotification(this, '#bind_EmailSendText,#bind_dvLabelEmailNotification');"> Send Email Notification </label>
        <br>
        <div id="bind_EmailSendText" style=" min-height: 120px; border:1px solid;padding:10px" contenteditable="true"></div>
        <input id="bind_EmailContents" name="EmailContents" type="hidden" value="">
      </div>
    </div>
    <div class="modal-footer">
      <div class="btn-group" role="group" aria-label="...">
        <button type="submit" id="btnBind" class="btn btn-success ">Save</button>
      </div>
    </div>
  </div>
</form>

POST /Application/SendForSignatureEnvelope

<form action="/Application/SendForSignatureEnvelope" enctype="multipart/form-data" method="post"> <input type="hidden" id="sendForSignatureAppObkey" name="sendForSignatureAppObkey" value="">
  <input type="hidden" id="sendForSignatureProposalId" name="sendForSignatureProposalId" value="">
  <input type="hidden" id="sendForSignaturePolicyId" name="sendForSignaturePolicyId" value="">
  <div class="table-responsive">
    <table class="table table-condensed">
      <thead class="customheader">
        <tr class="customheader1">
          <th>Envelope</th>
          <th width="110px"># Documents</th>
          <th width="170px" class="text-center">Created On</th>
          <th width="100px" class="text-right">Actions</th>
        </tr>
      </thead>
      <tbody>
        <tr>
          <td colspan="4" class="text-center"> There is no envelope created yet.<br>
            <a class="btn btn-success" href="/Document/ManageeSignatureEnvelope?obkey=487f60b9-d4c3-4290-a91a-9058980ed7ae">Create eSignature Envelope</a>
          </td>
        </tr>
      </tbody>
    </table>
  </div>
  <div class="row hide">
    <div class="col-md-12">
      <label id="sendForSignature_dvLabelEmailNotification">Email Notification Message:</label>
      <label class="pull-right">
        <input type="checkbox" name="IsSendEmail" value="true" checked="checked" onclick="fnShowHideDocsEmailNotification(this, '#sendForSignature_EmailSendText,#sendForSignature_dvLabelEmailNotification');"> Send Email Notification </label>
      <br>
      <div id="sendForSignature_EmailSendText" style=" min-height: 120px; border:1px solid;padding:10px" contenteditable="true"></div>
      <input id="sendForSignature_EmailContents" name="EmailContents" type="hidden" value="">
    </div>
  </div>
  <br>
</form>

Text Content

Toggle navigation
 * Log In
 * Register
 *  * English
    * Afrikaans
    * Albanian
    * Amharic
    * Arabic
    * Armenian
    * Azerbaijani
    * Basque
    * Belarusian
    * Bengali
    * Bosnian
    * Bulgarian
    * Catalan
    * Cebuano
    * Chichewa
    * Chinese (Simplified)
    * Chinese (Traditional)
    * Corsican
    * Croatian
    * Czech
    * Danish
    * Dutch
    * Esperanto
    * Estonian
    * Filipino
    * Finnish
    * French
    * Frisian
    * Galician
    * Georgian
    * German
    * Greek
    * Gujarati
    * Haitian Creole
    * Hausa
    * Hawaiian
    * Hebrew
    * Hindi
    * Hmong
    * Hungarian
    * Icelandic
    * Igbo
    * Indonesian
    * Irish
    * Italian
    * Japanese
    * Javanese
    * Kannada
    * Kazakh
    * Khmer
    * Kinyarwanda
    * Korean
    * Kurdish (Kurmanji)
    * Kyrgyz
    * Lao
    * Latin
    * Latvian
    * Lithuanian
    * Luxembourgish
    * Macedonian
    * Malagasy
    * Malay
    * Malayalam
    * Maltese
    * Maori
    * Marathi
    * Mongolian
    * Myanmar (Burmese)
    * Nepali
    * Norwegian
    * Odia (Oriya)
    * Pashto
    * Persian
    * Polish
    * Portuguese
    * Punjabi
    * Romanian
    * Russian
    * Samoan
    * Scots Gaelic
    * Serbian
    * Sesotho
    * Shona
    * Sindhi
    * Sinhala
    * Slovak
    * Slovenian
    * Somali
    * Spanish
    * Sundanese
    * Swahili
    * Swedish
    * Tajik
    * Tamil
    * Tatar
    * Telugu
    * Thai
    * Turkish
    * Turkmen
    * Ukrainian
    * Urdu
    * Uyghur
    * Uzbek
    * Vietnamese
    * Welsh
    * Xhosa
    * Yiddish
    * Yoruba
    * Zulu
   
   

Marcos Rubio Delfino
baguero@tdw.com
(713) 470-5300
Solo X
Quoted
11/18/2024


YOUR QUOTES


WORKERS' COMPENSATION

Select the policies you're interested in and click "Buy Now" to move forward.


SOLO X | QUOTED

Starts: November 18, 2024

Owner(s) excluded from WC coverage
Limits $500,000/$500,000/$500,000   |   Quote PDF

$1,075.00 per year

Buy Now


SIGN APPLICATION

By entering my name below I am verifying the information in this application is
true and complete to the best of my knowledge.

I agree to digitally sign Pogo's insurance applications and forms. View Legal
Agreements

SIGNATURE

Close Request Bind
Edit Info
×
Employer Liability Limits:
Employer Liability Limits $100,000/$500,000/$100,000 $500,000/$500,000/$500,000
$1,000,000/$1,000,000/$1,000,000 $500,000/$1,000,000 $1,000,000/$2,000,000
$2,000,000/$4,000,000

Effective Date:

Update
Overview
App ID: SLX3557
Insured
Name
Marcos Rubio Delfino
Company Name
Marcos Rubio Delfino
FEIN/SSN
11-0000000
State
GA
Email
baguero@tdw.com
Phone
(713) 470-5300
Class Code
5215
Rating State
GA
Employer's Liability
$500,000/$500,000/$500,000
Coverages
Workers' Compensation
Prior Coverage
No
Number of Employees
0
Submitted
11/18/2024 03:12 PM

Workers' Compensation
Employer's Liability
$500,000/$500,000/$500,000
Effective Date
11/18/2024
Expiration Date
11/18/2025
Days Prior to Renewal
TBD
Premium
$1,075
Carrier
SolePro




Edit details
×

Update

Bind Policy
×
Change Status Only?    (Use this option to change status without uploading
policy)
Bind Policy?
Change Status
Type of Document: Binder Policy
Policy Number:
Policy Number is required
Quote Offers: Workers' Compensation - SolePro - $1075.00 Manual Quote Offer
Quote Offers selection is required
Carrier: Select Accident Fund Amerisafe Amtrust Benchmark biBerk Builders Mutual
Chubb Combined CompWest Cowbell Employers FastComp Frank Winston Crum Hartford
Liberty Mutual Markel MEMIC Next Novatae Pie Sirius America SolePro
Carrier is required
Premium:
$
Premium required
Select File
Binder Document Required
Email Notification Message: Send Email Notification


Save
Processing Request
×
Processing Request, Please Wait...
Send for signature
×

Envelope # Documents Created On Actions There is no envelope created yet.
Create eSignature Envelope

Email Notification Message: Send Email Notification




App ID: SLX3557



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Processing Request
×
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app.pogo.co Open in urlscan Pro 209.10.86.16 Public Scan