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Workers Compensation Quote Form
Please fill in the information below to receive a quote
Primary Contact First Name Last Name
Years Company has been in Business
Company Type:
Number of Owners: Gross Sales
Tax ID or EIN
Number of Employees: Exclude Owners from coverage (check box if yes)?

Company Address:
: State: Zip
Phone:( Fax:( Email:
Type of Business & Description:
Please Describe Business in Detail:
States you do business In (Ctrl + Click to Select Multiple States)

Reason for Quote
Current Workers Comp Insurance Company (not agency):
Workers Comp Policy Expiration Date:
Workers Comp Policy Liability Limit:
Loss Modifier Code (will show on your dec page) NCCI # if Known
Workers Comp Losses in last 3 years?
Please describe any WORK COMP Losses give details and give dates

List Class Codes if known, Job Description, and Annual Payroll by Job Type
Class Code Job Description Employees in Job Class Annual Payroll
for Job Class
8810 Example - Clerical office 3 $ 90,000
  Gross Annual Payroll $
Do you use sub contractors?
How did you find out about us?


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