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Workers' Compensation Quote Request

Please provide as much information as possible to assure the most accurate quotes. Leave blank if you are not sure of an answer.

* Required fields.

General Information
Name of Business:
Name of Owners/Officers:
Contact Name: *
Contact Phone: *
Mobile Phone:
Contact E-mail: *
Address:
City:
State:	Zip:
Business Info:
Years in Business:
Fed Tax ID Number: *	Cannot quote without.
Business Description:

Current/Previous Insurance Information
Current Insurance Company:
Annual Premium:	$
Policy Period:
Effective Date:		Expiration Date:
Work Comp Modifier:	If known.
Will Officers be Included or Excluded - Please Explain:
Additional Officer Info:	List Owner(s) Names, Dates, & Percentage of Ownership (Percentages Must Total 100%):
Any Other Carriers (last 3 years):	Yes No If Yes, Please List Name(s) & Estimated Premium:
Any Insurance Claims Filed: (last 3 years)	Yes No If Yes, Please Give the Following Data: Date of claims, amount of claims, description, & cost of claims.

Payroll & Class Code Information
Class Code or Job Description:	Number of F-T Employees:	Number of P-T Employees:	Estimated Annual Payroll Per Class Code:
			$
			$
			$
			$
			$

List Any Additional Locations:

Do You Require Coverage Above Mandatory Limits?:	Yes No If Yes, Please Describe Required Limits:
Do You Work Outside of Your State?:	Yes No
Do You Use a Payroll Company?:	Yes No
If Yes, What Company?:

Additional Comments & Information

Please tell us anything else you think might be helpful to know in order to provide accurate insurance quotes.

Attach Files:

Please attach written request(s) and/or contracts received, if any.

File #1:

File #2:

File #3:

Please click the "Submit Quote Request" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.