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Call: 800-513-3967

To start your Worker’s Comp Insurance Quote, just fill out the required information below. For a more accurate quote, you can fill out more information on the following secure pages.
Fill out as much information as you want. You may skip any of the following questions, but the more information you provide, the more accurate your quote will be.

Business Information

Business Name:

Address:

City:

State:

Phone:

Zip:

Fax:

Business Type:

Industry:

Describe your Business:

Annual Gross Sales:

Number of Full Time Employees:

Number of Part Time Employees:

Estimated Monthly Payroll:

Number of Locations:

Years in Business:

Federal Tax ID (FEIN):

Federal Tax ID (FEIN):

Business Type:

License Number:

Owners/Partners/Officers (Include yourself if applicable.)

Number of Owners/Partners/Officers:

Owner 1

Owner Name:

Date of Birth:

Title:

Ownership %;

Payroll Information

Number of Employee Groups:

Employee Group 1

Class/Code (Group 1):

Payroll Rate (Group 1):

Annual Payroll (Group 1):

Misc. Information

Do you offer safety programs?

Do you offer health benefits?

Do you employ any minors?

Do you use sub-contractors?

Do you use any equipment that bends/forms/shapes?

Do you sponsor any athletic teams?

Do you do any work up over 15 feet?

Is the business open 24 hours?

Is the business involve any deep frying of foods?

Is the business involve any filling of propane tanks?

Have you filed bankruptcy in the past 7 years?

Are you a member of any trade organization?

Do you have operations outside the state where you are domiciled?

Coverage Information

Current Carrier Name:

Policy Expiration:

Current Premium Amount:

MOD Factor:

Coverage Description:

Has coverage lapsed in past 12 months?

New Coverage Liability Limit:

Losses/Claims

Number of Losses Claimed in the Past 5 Years:

Additional Information

Agent Name (Optional):

How Did You Hear About Us?

Preferred Contact Method:

Additional Comments: