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Pay as You Go Workers' Compensation Quote

  General Information
Name of Business:
Name of Owners/Officers:
Contact Name: *
Contact Phone: *
Contact Fax:
Contact Email: *
Address:
City:
State:
Zip:
Business Info:
Years in Business:
Federal Tax ID Number: *
Business Description:*

  Current/Previous Insurance Information
Current Insurance Company:
Annual Premium:
Policy Period:  
Effective Date: Expiration Date:
Work Comp Modifier:
Will Officers be included or excluded - please explain:
Additional Officer information: List Owner(s) Names, Dates and Percentage of Ownership (Percentages must total 100%)
 
Any other carriers (last 3 years): Yes   No
If yes, please list name(s) and estimated premium:
Any insurance claims filed (last 3 years): Yes   No
If yes, please list date of claims, amount of claims, cost of claims and a description 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 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.