Workers Compensation Quote Request Form

BUSINESS INFORMATION:
* Indicates a required field
Business Name: *
   Type:
   If other, please specify:
Street Address:
Mailing Address:
City:
State:
Zip Code:
Primary Contact Name: *
Primary Contact Email: *
Secondary Contact Name:
Secondary Contact Email:
Telephone with Area Code: *
Fax:
FEIN:
Years in Business:
Current Workers Comp Insurer: (company):
Policy Number:
 

BUSINESS DESCRIPTION:
Brief description of business operation:
 
Class Code Class Description Annual Payroll Number of Employees
 
Do you lease employees? Yes  No 
Do you have a written safety program? Yes  No 
Do you have a drug testing program? Yes  No 
 

OWNERSHIP INFORMATION:
(Owners are excluded unless otherwise directed or coverage is required by law)
Name Title Percent Ownership Excluded Y/N
 

MISCELLANEOUS INFORMATION:
Property/Casualty Insurer (company):
Expiration Date:
May we provide you with competitive quotes? Yes  No 

Do you provide group health insurance to employees?

 Yes  No 
Who were you referred by?
Are you already working with one of our agents? Yes  No 
If yes, who?
 
A copy of this form will be sent to your email.
Submit this form:  

 
How to Contest a Medical Bill
For lots of us contesting a bill takes guts. Challenging caregiver bills after they’ve just saved your life is downright ulcer-inducing. But you should if you think something’s wrong or the bill is high. Read more...
Recent News