Worker's Compensation Form

Worker's Compensation Quote

We would like to provide you with a free, no-obligation Workers' Compensation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Business:  
Contact Name:  
Address:  
City:     State:     Zip:  
Business Status:       Other:  
Business Tax ID Number:  
Business Phone:     Fax:  
Best Time To Call:     AM   PM
Contact Email Address:  

Current Insurance Information
Company Name (not agency):  
Policy Expiration Date:     Premium Amount: $ 
NCCI Number:  
NCCI Experience Modification Number:  
What type of coverages do you currently have:
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Other    

About Your Business
# of full-time
employees
# of part-time
employees
How long
in business
How many
locations
Estimated Annual
Payroll
 
 
  years
 
Please give a brief description of your business(below):

Employee Information
Employee#
Classification Code or Job Description
Estimate Yearly Payroll
1
 
2
 
3
 
4
 
5
 
Please list additional employees in the "Additional Comments" section below

Business Information
Please select all that apply to Business:
Operate or Lease aircrafts/watercrafts
Store, treat, dispose or transport hazardous waste
Work Underground
Work above 15ft.
Work on vessels, docks or bridges over water
Require out of State travel
Use Subcontractors
Delievery Service
Pre-employment Physicals
Offer Safty and Incentive programs
Other    

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

       

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