WORKERS COMP INSURANCE QUOTES

Give us some general information about your business and we will get you started

First Name

Last Name

Email

Phone

Legal name of business ?

Are the mailing address and business location the same ?

Yes

No

Is the name of the applicant the same at the owners ?

Yes

No

Are the mailing address and business location the same ?

Yes

No

Name of owners of the business ?

Type of Business ? (General Description)

How long have you been in business ?

Requested effective date ?

Do you currently have insurance ?

Name of Current Insurance Company ?

Expiration date of current policy ?

Do you currently have a payroll company ?

Name of payroll company ?

Estimated amount of annual payroll ?

Do they calculate your Workers Comp premiums per pay period ?

Yes

No

How many employees do you have?

Have you had any claims?

Yes

No

What type of claim ?

(Optional) What is the most important thing to you?

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