workers compensation quote request

Company Information

Company Name:
DBA:
Street Address:
City:
State: Zip:
Phone Number: Fax Number:

Mailing Address (if different)

Street Address:
City:
State: Zip:
FEIN# (must be 9 digits): SS#:
Contact Person:
Phone Number: Email:

Company Description

Legal Entity type: Sole Proprietor
Partnership
Corporation
LLC
Other
Requested effective date: Years of relevant experience: Year Business was Established:
Description of business operations:
Number of full-time employees: Number of part-time employees:
Job Description-Employee 1: Estimated Annual Pay: F/T P/T
Job Description-Employee 2: Estimated Annual Pay: F/T P/T
Job Description-Employee 3: Estimated Annual Pay: F/T P/T
Job Description-Employee 4: Estimated Annual Pay: F/T P/T
Job Description-Employee 5: Estimated Annual Pay: F/T P/T
(If applies) Prior carrier: Policy #:
Current Premium: Any claims:
Loss Runs Available? Yes No
Completed By:

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